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What is cross-Disability solidarity? And how do we make accessible culture and gathering spaces? Join us in a 6-week relaxed virtual space with asynchronous options to discuss ways cross-Disability communities collaboratively hold accessible gathering and cultural spaces.

Each recorded two-hour session features an embodiment warm up led by a Disabled artist, a short text read aloud by live participants, and group discussions to reflect on the reading. Each session covers different material and doesn't have to be followed in a particular order. We will also invite each participant to use their own personal bodymind experience of Disabling circumstances as a primary source of information. This is an anti-ableist, anti-racist, queer- and trans-positive space centering the needs and voices of multiply-marginalized Disabled folks, and is open to all.

Dis/Rep 2023 is co-produced by The Curiosity Paradox, Calling Up Justice, and Catalyst Consulting Associates.

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Our Zoom sessions feature baseline access of ASL by a Deaf and hearing interpretation team, as well as automated captions. Facilitators will describe visuals. It is ok to be off camera, and it is ok to arrive or leave at your comfort. Each session will cover different material and you may join as many as you want, or just access recordings to participate.

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Any views, findings, conclusions, or recommendations expressed in Dis/Rep do not necessarily represent those of the City of Portland. (Regardless of how clever, accurate, or outlandish they may be.)

About Dis/Rep

Dis/Rep (Disability Representation) is a yearly series of virtual engagements focused on Disability, accessibility, and culture that began in 2020 as a relaunch of the program started by Disability Art and Culture Project. It utilizes a variety of formats, including book club-style discussions, a Discord server for asynchronous participation, web content, and remote engagement activities. The project is designed as an anti-ableist, anti-racist, queer, and trans-positive space, centering the needs and voices of the Disability community.

Dis/Rep 2020: Reading the Disability Justice Primer

Dis/Rep 2020 was produced by The Curiosity Paradox and Calling Up Justice. During four workshops, we explored the Sins Invalid Statement on Police Violence, the Principles of Mixed Ability Organizing, Disability Liberated, and Disability Justice Timelines from Skin Tooth and Bone: The Basis of Movement is Our People. These topics were particularly relevant at the time, as George Floyd had been murdered and the entire country was reacting to the incident and the widespread protests that followed.

Dis/Rep 2021: #AccessIsLove In Action

In Dis/Rep 2021 we discussed #AccessIsLove, with concepts such as valuing disabled expertise and expanding what "access" means. In 2021, producers from from Calling Up Justice, The Curiosity Paradox, and Rebel Black joined with creative access consultant Deanna Yadollahi and guest facilitator Jennifer Kemp. Embodiment artists Maya Johnson, Paula Rupert, Yulia Arakelyan, Sidoney O'Neal, Matthew Reynolds, and Scott Selby led embodiment exercises for the 2021 sessions.

Dis/Rep 2022: Liberating Words

Dis/Rep 2022: Liberating Words had everyone exploring ideas from National Disability Theater, Sound Theater, Claudia Alick, Grant Miller, Jonathan Paradox, Rebel Sidney Black, Sins Invalid, TL Lewis, Sunaura Taylor, Kimberly Crenshaw, Audre Lorde, Keri Gray, Imani Barbarin, Stacey Milbern, Dustin Gibson, Unsettling Dramaturgy (The Crip and Indigenous Process Design Research Colloquium), Aurora Levins Morales, Rebel Sidney Black, Leah Lakshmi Piepzna-Samarasinha, Mia Mingus, John Lee Clark, and Luticha Doucette on Philosopher Éduoard Glissant. All our sessions were facilitated by experienced professionals and featured readings, embodiment exercises, group discussions, and other interactive elements. This was a coproduction of The Curiosity Paradox, Calling Up Justice, and Leaping Water Consulting, with disabled embodiment artists Anita Hollender, Luticha Doucette, Monetta Wilson, India Harville, Toby McNutt, and Carmen Papalia, leading exercises in the 2022 sessions. Luticha also joined as a guest facilitator. Dis/Rep is continuing in 2023 with Catalyst Consulting, The Curiosity Paradox and Calling Up Justice.

Dis/Rep is a valuable resource for disabled individuals and our supporters, empowering us to engage with contemporary issues and be heard and understood. It is a testament to the importance of centering disabled voices, particularly multiply-marginalized Disabled people, in contemporary discussions and events and works to create a more inclusive and accessible world for all.

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Dis/Rep (Disability/Representation) is a yearly series of virtual dialogues focused on Disability, accessibility, and culture. It is currently co-produced by The Curiosity Paradox, Calling Up Justice, and Catalyst Consulting Associates LLC.

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hi im bee (ꈍᴗꈍ) ~ a community focused, soft-spoken & silly creator who loves to share their latest hyperfixation with you! come co-exist?

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Rapid Response Tech Team - Calling Up Justice!

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At Calling Up Justice our Rapid Response Tech Team is dedicated to helping us produce quick turnaround programming that swiftly responds to injustice.

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I'm alive, bitches! My recent column in Teen Vogue about the surge and its impact on me as a high risk disabled person became a terrifying reality when I had a medical emergency that required a visit to the ER and brief hospitalization in the ICU.

Disabled, immunocompromised, and chronically ill people know fully well that the world is not designed for us and how we are often dehumanized and considered burdens by the medical industrial complex. It is an exhausting struggle to be seen and heard while fighting to survive in the face of systemic oppression.

While I was in the hospital I tweeted some of my experiences because I needed to document what was happening and do something while filled with fear.

Writing and organizing is a way to channel my rage and process my medical trauma.

I call upon you all to help me push for a N95 mask mandate at UCSF Health.

No one should have to delay care or risk infection from COVID when receiving necessary medical care.

Even if you are not a patient at UCSF Health or resident in the Bay Area, here's what you can do.

Steps to Take

Read the complaint I made to the Office of Patient Relations (see below).

Email them to demand UCSF Health require that all staff, visitors, and patients wear a N95 mask in all of their locations.

In your email to the Office of Patient Relations CC the leaders (see below) and BCC me so that I can keep track at N95Masks4UCSF@gmail.com

Share why you think a N95 mask mandate it's important for public health and if you are a patient or reside in the SF Bay Area. Do not claim to advocate for or on my behalf. Feel free to cut and paste my primary and additional policy recommendations and any other systemic changes you would like to see at UCSF Health. I did not provide a sample letter because I want you to tell your story and experiences.

If you are part of an organization, try to get it to submit a message as well.

Tag @UCSFHospitals and use the hashtags #N95s4UCSF #KeepMasksInHealthcare with a copy of your written response or a link to this blog post.

Encourage your friends, colleagues, and family to do the same.

Let's keep each other safe! Also, if you are looking for free N95 masks, here's a link from the CDC to local clinics and health centers that give away free masks. And you can find your find your local mask bloc here.

PS: If you'd like to support me, you can make a donation to my GoFundMe or share it which helps defray the out-of-pocket costs for my caregivers so that I can live in the community and have a life.

For more:

Transcript and links for our episode #N95s4UCSF with @SFdirewolf: https://t.co/E4Gmk3k4LJ

- Death Panel (@DeathPanel_) February 1, 2024

Content notes: medical trauma, hospitalization, systemic ableism, death, anxiety, images of injury
Letter to Office of Patient Relations, UCSF Health

TO: Office of Patient Relations, UCSF Health
patient.relations@ucsf.edu
CC: Suresh Gunasekaran, President, CEO
suresh.gunasekaran@ucsf.edu
Elizabeth Engel, Vice President, Chief of Staff to the CEO
elizabeth.engel@ucsf.edu
Joshua Adler, Executive Vice President, CFO, Vice Dean,

UCSF School of Medicine

Sheila Antrum, COO, Senior Vice President

Cynthia Barginere, President of Adult Services, Senior Vice President and President of Adult Services
cynthia.barginere@ucsf.edu
Corey Jackson, Senior Vice President, Human Resources

Adeena Khan, Medical Director, Moffitt-Long Medical Service

Molly Kantor, Associate Medical Director of Moffitt-Long Medical Service

January 25, 2024

Hello, my name is and I have been a patient at UCSF Health for over thirty years and am an alumna of the Department of Social and Behavioral Health. I am filing a patient complaint regarding my experience in the ED (emergency department) and ICU (intensive care unit) at Moffitt/Long Hospital January 20-21, 2024.

I am including key members of leadership involved in innovation, patient services, employee safety, clinical services, strategic priorities, and human resources, because I am reporting systemic issues based on my individual experience that are not reflective of UCSF Health's mission, visions and values.

I am a high-risk disabled person who is vulnerable to dying from COVID. Wearing a N95 mask is not effective for me since I cannot breathe through my nose or mouth and the in-line bacterial filter attached to my ventilator cannot protect me from COVID and other airborne viruses.

Last Thursday my j-tube cracked making it unusable. Similar to previous incidents, I relied on the other (g-tube) for feeding, hydration, and medication as I am unable to eat by mouth or swallow until my outpatient appointment with IR (interventional radiology) at Moffitt/Long on January 23, 2024. With increased pain at the site of my stomach stoma and a distended, rigid, and tender abdomen that developed on Friday and Saturday, I reluctantly went to the ED because the pain became intolerable.

Aware of the current surge due to the JN.1 variant , I delayed going because of exposure and potential infection. Here are several elements to my complaint.

OVERALL
My concerns were minimized by several health care providers. I was not heard and seen as a human being. I did not receive I am not safe receiving medical care at UCSF. This is not a "feeling." This is a fact for myself and a significant percentage of your vulnerable patient population who are part of This is a public health, infection control, and patient/workplace safety issue. The Viral Underclass effective, safe, timely and equitable quality of care . I was harmed and traumatized.
Lack of adequate masking

Being led to my room in the ED, I was distressed to see so many patients unmasked and coughing and majority of health care providers either unmasked or only wearing a surgical mask

I requested a sign asking all people entering my room to wear a N95 posted outside the door

A respiratory therapist came in and responded, "I don't normally wear N95s. You are not airborne!" A RT who does not understand 1) my request was not unreasonable; 2) I am clearly a high risk disabled patient with a tracheostomy who is vent-dependent; 3) the dangers of airborne viruses in enclosed, crowded spaces are significant especially in a medical setting. Unable to speak, I wanted to say, "I am surrounded by airborne pathogens in the ED. I'm not the infectious one (yet), I am the one who needs protection." This was a truly disturbing interaction.

In IR the next day, the technician who set up the sterile field on my abdomen had a persistent cough the entire time while wearing a surgical mask. I could hear him in the back room during my procedure continuing to cough and clear his throat.

I returned to the ICU after the g-j tube was replaced and requested to speak with the care team informing them about this complaint. My family friend verbally relayed my intentions and one doctor explained that staff are not obligated to wear N95s and surgical masks are the only ones they can wear by choice, ignoring my reasonable concerns. Another doctor proceeded to explain that my procedure took longer than expected which was not my chief complaint. The two doctors suggested I was anxious and needed to calm down. I mouthed my response translated by my friend that my "anxiety" is actually anger at the way I was treated at IR and the excruciating pain I experienced (see below).

Communication access and inadequate pain relief

The IR nurse said I could have pain medication and administered Versed; the ICU nurse who accompanied me to IR administered multiple doses of Fentanyl throughout the procedure to no avail.

No one asked the two radiologists to pause for a few seconds for the drugs to take effect during the procedure. I was in agony and powerless to stop anything.

Upon return to the ICU, my heart rate was over 200 beats per minute chalked up as "anxiety."

The ICU team further defended the lack of communication access, a right under the ADA , due to the need to maintain a sterile field in IR which meant I could not write anything down as if it was my fault for being a non-speaking person. Healthcare providers know how to work with all kinds of bodies. I have no doubt Speech and Language Pathology or other departments could advise for a solution that does not endanger a sterile environment for procedures and surgeries. However, the ICU care team intimated it was an impossibility which I found disappointing.

Primary Recommendation

Patients come to the ED under great stress, fear, uncertainty, and discomfort. It is incredibly difficult to advocate for the bare minimum under such duress. Why should I have to opt in and request safety measures when it should be the default for everyone? No one should be unnecessarily at risk in outpatient (especially chemotherapy), emergency, and inpatient settings.

With my complex medical needs, extensive experience navigating the healthcare system, and ability to advocate for myself, I expect long wait times , discrimination, and barriers to care and understand how hospitals are overcapacity along with financial and other strains. However, it should not take a pandemic, threat of legal action, or crisis for institutions to improve their practices. As a society, we cared for one another and found the political will and resources to pivot when the pandemic emerged in 2020 only to regress to a "vax and relax," "you do you" mentality where the burden to stay safe is an individual responsibility rather than a collective one creating conditions for future surges, new mutations, more people developing Long COVID (which is underfunded and under researched ), and new outbreaks of COVID, measles, RSV, flu, and other infectious illnesses.

Mitigation measures that can reduce hospitalizations, reduce workforce shortages, prevent delayed care (which can be more costly), protect immunocompromised, and high risk patients and staff, and decrease community transmission should be part of UCSF Health's mandate which are firmly aligned with its mission and reputation as a world-class research and healthcare institution.

Additional recommendations

Free PCR tests for all UCSF Health staff

Installation of UV lighting and/or upgraded ventilation/filtration at all UCSF Health locations

Partner with a nonprofit or manufacturer to mail free N95 masks to all patients for their future appointments and visits to UCSF Health

Partner and support local mask blocs and other community-based efforts that promote COVID precautions

Update HR and infection control policies to require masking, isolation protocols, and reporting of positive results for airborne illnesses

Establishment of COVID safety workgroup with representatives from patients, staff, and community members that has the directive to gather feedback and outline actionable items to UCSF Health leadership

Rationale

My proposed recommendations invites UCSF Health to invest in infrastructure and their people to protect everyone now and in the future. By integrating science-driven, evidence-based improvements that raise the bar above legal compliance, UCSF Health will be a leader that puts their commitment to equity, diversity, culturally competent care, and excellence into practice in tangible ways ensuring the wellness of the public.

I can already imagine the response to this letter: "We are not obligated to go beyond what is legally required," "We do not have the resources or money to institute these changes," "These changes will take years of planning and implementation," and "Staff, patients, and visitors will object and this for privacy and civil liberties reasons and it will open us up to legal actions by them." These are my counterarguments:

Compliance to the law is a low bar. Real leadership recognizes that progress can only happen by being creative and having the foresight to go above and beyond what is expected; to have a vision for a more equitable and accessible world.

When the pandemic first emerged in March 2020, institutions like UCSF Health responded with urgency and were able to find the money and resources to continue providing care (e.g., online appointments via Zoom). The pandemic is not over nor is it endemic; surges, outbreaks, and new pandemics will continue to happen and hospitals need to take a proactive approach to reducing risk that will also be cost effective and beneficial to all.

I am old enough to remember the controversy on campus when smoking in public spaces was banned when I was a staff research associate at the Institute for Health and Aging. People used to smoke inside hospitals. Handwashing during medical procedures took over a hundred years to become standard practice despite the knowledge that it would reduce the spread of pathogens which cost many doctors their careers for being early adopters. UCSF Health shouldn't let the fear of pushback and resistance to uptake hinder its duty of care to their patients, visitors, and staff.

As the second largest employer in San Francisco with approximately 2.5 million outpatient visits and 42,000 inpatient discharges annually , UCSF Health can make a huge impact on the wellness of the entire region by instituting a robust set of COVID mitigations strategies that can become a national model for other healthcare systems.

For more: A CDC Update on the Draft 2024 Guideline to Prevent Transmission of Pathogens in Healthcare Settings

I look forward to your response and am available if you have any questions.

Alice Wong, a disabled patient that wants UCSF Health to do better

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N95s4UCSF: Call to Action I'm alive, bitches! My recent column in Teen Vogue about the surge and its impact on me as a high risk disabled person became a terrifying reality when I had a medical emergency that required a visit to the ER and brief hospitalization in the ICU.

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As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.
Learn more: PMC Disclaimer | PMC Copyright Notice

Front Public Health. 2023; 11: 1161881.

Suzy Huijghebaert, 1 , * , † Shehzad Parviz, 2 , 3 David Rabago, 4 Amy Baxter, 5 Uday Chatterjee, 6 Farhan R. Khan, 7 Cristoforo Fabbris, 8 Konstantinos Poulas, 9 and Stephen Hsu 10 , 11 , International Network on Saline Clinical Use

Abstract

With unrelenting SARS-CoV-2 variants, additional COVID-19 mitigation strategies are needed. Oral and nasal saline irrigation (SI) is a traditional approach for respiratory infections/diseases. As a multidisciplinary network with expertise/experience with saline, we conducted a narrative review to examine mechanisms of action and clinical outcomes associated with nasal SI, gargling, spray, or nebulization in COVID-19. SI was found to reduce SARS-CoV-2 nasopharyngeal loads and hasten viral clearance. Other mechanisms may involve inhibition of viral replication, bioaerosol reduction, improved mucociliary clearance, modulation of ENaC, and neutrophil responses. Prophylaxis was documented adjunctive to personal protective equipment. COVID-19 patients experienced significant symptom relief, while overall data suggest lower hospitalization risk. We found no harm and hence recommend SI use, as safe, inexpensive, and easy-to-use hygiene measure, complementary to hand washing or mask-wearing. In view of mainly small studies, large well-controlled or surveillance studies can help to further validate the outcomes and to implement its use.

Keywords: saline, COVID-19, nasal irrigation, gargling, nebulization, nasal spray, respiratory infection

Keypoints

Oronasal saline irrigation is an inexpensive intervention to prevent and relieve common colds and upper respiratory infections.

COVID-19 patients may also benefit, as saline irrigation of the nose and throat was found to reduce nasopharyngeal viral load, fasten viral clearance, and relieve symptoms of COVID-19.

Overall, the small studies point to a potential benefit of saline irrigation on transmission, hospitalization, oxygen need, ICU admission, and/or mortality; confirmation in large trials is warranted.

Mechanisms of saline include, apart from the rinse effect that can limit micro-aspiration of virus and secretions from the nasopharynx to deeper airways and lungs, also direct effects of iso- or mild hypertonic saline on SARS-CoV-2 replication (impairment of growth and fusion in vitro), mucosal hydration, mucociliary clearance, ENaC channel activity, and obstructive mucus/NET formation, all mechanisms that can help to reduce and prevent the development of more invasive severe disease.

Oral and nasal saline rinsing can be considered for prevention and as an early intervention in SARS-CoV-2 infection, adjunctive to current standard protection including mask wear, distancing, and hand hygiene.

Saline nebulization can be considered in patients who cannot do saline irrigation, or with lower respiratory tract signs or symptoms: The released bioaerosol does not contain live virus.

1. Introduction

In the ongoing COVID-19 pandemic, measures to limit the spread of SARS-CoV-2 have been a continuous and evolving challenge ( 1). Continuous mutations of its spike (S) protein circumvent effective vaccine and monoclonal antibody development ( 2, 3). New antiviral treatments are expensive and subject to side effects ( 4). Saline irrigation (SI) of the nose and throat is an inexpensive hygienic option that is proven effective for reducing the burden of other viral, bacterial, and acute or chronic respiratory illnesses ( 5- 8) and has been empirically suggested as option for SARS-CoV-2 mitigation ( 9- 12). Today, SI is also removed from the general WHO myth buster page ( 13, 14). While consensus guidance on its use has recently been proposed in China by a Chinese Rhinopathy Research Cooperation Group ( 15), published evidence for the utility of SI as adjunctive hygiene in COVID-19 has yet to be reviewed. We conducted a narrative review of this topic and present the clinical evidence and currently understood mechanisms for SI's efficacy in COVID-19 and propose recommendations for use and further evaluation.

2. Methods

Mixed methods were used for this descriptive review, generated with systematic search strategies, as described in the Supplementary Appendix Part A. The objectives of the reviewing process were to review the evidence for saline in COVID-19 by (1) evaluating clinical outcomes obtained with saline as (oro)nasal irrigation fluid or gargling in COVID-19 or SARS-CoV-2 infection and (2) exploring clinically relevant mechanisms of how these outcomes may be achieved-this with the objective to consolidate benefits and risks, as well as formulate recommendations. Nebulization was added as the search term to allow assessment of the harm-benefit balance of this procedure, often discouraged in COVID-19 ( 16).

The search strategies for the clinical data and mechanisms of action are reported in Supplementary Appendix Part A.1. p. 02-05, ( Supplementary Table S1) and Supplementary Appendix Part A.2. p. 10-11 ( Supplementary Table S2), respectively. With the literature on saline being abundant, a stricter search strategy was conducted for clinical reports of relevance on PubMed from 1 January 2022 to 27 October 2022 ( Figure 1 ). Initial screening of clinicaltrials.gov and WHO trial databases had revealed that saline was not the subject of a large public or developmental program, while it was often also serving as a reference or placebo, which explains the substantial heterogeneity of study designs. Therefore, studies were eligible, irrespective of whether saline (irrigation, mouth rinse, gargling, spray/drop, or nebulization) was the subject or the reference/placebo of the study. In view of the exploratory nature of this review, additional searches on the Internet and PubMed were performed, with the use of additional search terms, described in Supplementary Appendix, p. 03, such as a clinical trial or clinical study, nasal sprays or drops, or using the protocol numbers from trial databases, as to retrieve eventual results. The material was progressively compiled. Details on reasons for rejection of sources are listed in Supplementary Appendix, p. 03-06 and p. 10, respectively. Most studies were small. If a bias was identified, this was noted in the tables and/or discussed in the text. In total, 33 clinical studies or reports were eligible and tabulated, which are stratified ( Supplementary Appendix, p. 06, 07) by the effects of saline on viral load and/or clearance ( Supplementary Table S3, p. 11) and/or effects on clinical outcomes ( Supplementary Table S4, p. 17). Rates of hospitalization and risks (intensive care uptake, pneumonia severity scores, ventilation, and mortality) were compiled separately in Supplementary Table S5, p. 30. Grading, pooling, or meta-analysis of outcomes was not performed due to often small-sized (local) studies, substantial heterogeneity in study design, disease severity and outcome parameters, and/or poor or limited data reporting.

For the mechanisms of action of saline of relevance to COVID-19, initial search strategies ( Supplementary Appendix, p. 10) addressed the effect(s) of saline on SARS-CoV-2 viral load (aspiration), replication, exhaled bioaerosol, ENaC channel activity, hydration and mucociliary clearance, neutrophil response, and hypochlorous (HOCl) formation. Yet, mechanisms were also examined from a broader translational view by the Network. As the COVID-19 literature is extensive, sources were limited to one (if consistent) or the most representative articles or reviews (if multiple sources or reviews). The mechanisms addressed and found in support of SI are summarized in Figure 2 .

The findings of the review process were compiled according to (A) the major mechanism documented clinically for saline irrigation (viral load reduction) and its relevance to transmission, (B) additional mechanisms that can be effectuated by saline mucosal irrigation, and that may be protective in the initial stage of COVID-19 (sodium chloride (NaCl) homeostasis and innate immune response), and (C) clinical outcomes of studies in COVID-19. Clinical benefits, risks, lessons learned, recommendations, and conclusion were formulated and reflect the final consensus in January 2023, after evaluation and discussion of the benefit-harm balance, based on the consolidated findings from the tabulated data.

3. Results

3.1. Viral load reduction and transmission

3.1.1. SARS-CoV-2 pathophysiology: rationale for viral load reduction

Similarly as for common colds ( 8), the main rationale proposed for using saline irrigation is to rinse the nasal and throat mucosa, removing SARS-CoV-2 and limiting the viral load from these tissues.

Nasal multiciliated cells are primary targets for the entry of SARS-CoV-2 ( 17), which after replication are released at their apical side ( 18), allowing rapid reinfection and progressive epithelial damage, with a spread from the naso- and oropharynx to the deeper throat and airways. The infection initially starts almost exclusively in the ciliated epithelia of the nose ( 19), while micro-aspiration of virus, sputum, mucins, and inflammatory secretions from the oral and nasal cavities is increasingly recognized as the main mechanism for infecting deeper airways and lungs ( Figure 2 ) ( 20- 22). This pathway in SARS-CoV-2 pathophysiology is supported by the findings of (upregulated) expression patterns of SARS-CoV-2 entry genes (such as ACE2 and TMPRRS2) and broad nasal, buccal, and blood gene expression analysis, the absence of alveolar macrophages and alveolar invasion at onset of the disease, the difficulty to infect human lung tissues with SARS-CoV-2 in vitro (in contrast to nasal and in vitro host cells), and the progressively observed immune gene upregulation ( 20- 25). In addition, mucin secretions are abnormal and become upregulated, as well as nasal inflammatory cytokines ( 26, 27). Mucins often present as viscous plugs obstructing the trachea and bronchi (see also Section 3.2.2.). The highest viral loads are detected in sputum, followed by nasopharynx, while these are usually lower in saliva ( 28- 30). Moreover, development of viral SARS-CoV-2 RNA shedding and bronchopneumonia was found to be dose-dependent in response to the dose of virus intranasally delivered, supporting the concept that rinsing off virus in an early stage may reduce disease development and severity ( 31). To further illustrate the importance of the removal of aerosolized secretions, it is important to note that elements of the virus itself, such as the released S proteins, can generate inflammation and tissue damage in the picomolar range, as well as bind multiple innate immune receptors, contributing to the disturbed local immune response ( 32, 33)]. An in vitro study showed that endothelial cells are normally not invaded by SARS-CoV-2; following viral replication, however, epithelial released cytokines and components induced during the infection affected the neighboring endothelial cells, resulting in damage of the epithelial/endothelial barrier function and causing the viral dissemination ( 34). Observations that the cytokine levels in sputum, and not serum, are predictive for lung damage and prognosis of severe COVID-19 ( 35), and that mucus surprisingly releases finer aerosol particles the more its viscoelasticity decreases ( 36) (dry plugs common in COVID-19), support further the concept of micro-aspiration of virus and infected bioaerosol to the deeper airways and lungs.

Micro-aspiration of virus and secretions from the oronasal cavity not only allows progressive viral invasion of deeper airways and lungs causing COVID-19 pneumonia but also may contribute to severe co-infected pneumonia: Viral, bacterial, and fungal secondary infections are common in SARS-CoV-2 patients, and viruses, bacteria, and fungi were frequently found in the plugs removed from the trachea and bronchi during bronchial/tracheal lavage ( 37- 40). Studies on microbiota identified depletion of beneficial commensals and an upsurge of opportunistic pathogens, also in the oral and nasopharyngeal cavity ( 41).

Higher SARS-CoV-2 viral loads and longer virus shedding have been associated with disease severity and disease progression, as well as with transmission ( 42- 44). Hence, their reduction may help to avert the infection, reduce micro-aspiration of the virus to the lower respiratory tract, and prevent the progression to a more severe disease state. Earlier studies in other respiratory conditions have shown that nasal SI helps to remove pathogens, allergens, debris, and secretions from the nasal cavity and reduce sinonasal and respiratory infections ( 6- 8, 10, 45), while respecting the normal sinonasal commensal microbiome ( 46). SI is, therefore, a reasonable choice to reduce viral loads and micro-aspiration during COVID-19 and potentially help prevent the development of pneumonia and acute respiratory distress syndrome (ARDS).

As both the nasal and oropharyngeal cavity may become infected, and so may lead to both micro-aspiration of the virus to the lungs and exhaled infectious bioaerosol, and so to airborne transmission, (also via saliva) ( 47), the effects of nasal irrigation, gargling and nebulization of saline on viral loads, bioaerosol formation, transmission, and prophylaxis are considered in this section.

3.1.2. Rinse effect reducing viral loads

Fifteen studies were identified, reporting on the effect of saline gargles ( n = 4) and SI ( n = 9) or nasal spray ( n = 2) on viral load or clearance to PCR-negative status ( Supplementary Table S3, p. 11). Symptomatic and asymptomatic patients, different saline concentrations (0.9-5%) and schedules, routes (nasal, gargling, and combined), and methods of SI (neti pot, spray or pressurized bottle, or lavage system) were evaluated ( 48- 62).

The studies and their outcomes are schematically represented by salivary, nasopharyngeal, and mid-turbinate viral load testing, and their randomized (RCT) or non-randomized controlled trial (non-RCT) designs are shown in Figure 3 . Overall, studies in COVID-19 patients report that single-day and repeated SI reduces nasopharyngeal viral loads.

3.1.2.1. Single gargle studies (n = 3)

Two studies evaluating the effect of a single gargle (after 5 or 30 min) of an antiseptic mouth rinse vs. a short 30-s 10-20 mL saline gargle (control) did not find significant intergroup differences in mean salivary viral load reductions between saline and the antiseptic mouth rinses ( 49, 50). In another study, the median salivary viral load wa s reduced by 89% at 15 min after gargling 20 mL of saline for 60 s (90% after 45 min) vs. baseline. The median changes were similar for the three antiseptic comparators varying between 61-89% and 70-97%, respectively, while mean reductions (25-75%) highly fluctuated in values ( P > 0.05 upon intergroup comparison) ( 48). There was, however, a significant correlation between baseline viral load and reduction at 15 min ( P = 0.0073) and persistence at 45 min ( P = 0.0087) for all mouth rinses tested. In cases where the viral load was <10 ⁴/mL copies, a 100% reduction was obtained ( 48).

3.1.2.2. Single-day SI studies

Mean nasopharyngeal viral load in hospitalized COVID-19 pneumonia patients was reduced by 17.3% (median 23.6%) with hypertonic saline after three nasal SIs performed within 6 h while not among the small control group (not reaching significance) ( 52), while a larger randomized controlled study with 0.9% SI, 10 mL in each nostril every 4 h for 16 h, found a significant reduction in nasopharyngeal viral load at 24 h vs. the control group ( P = 0.005) ( 51).

3.1.2.3. Repeated SI studies

After 3-10 days of oronasal SI, fast(er) viral clearance was observed compared with controls in most studies ( 51, 54- 59). Start of SI immediately after testing cleared the virus in 91% of patients on Day 10 vs. 28% in matched controls not receiving SI ( P < 0.0001) ( 54). Even a delayed start of SI (7 days after testing) also favored its use in a prospective non-RCT ( 55).

In three RCTs, it was shown that SI or nasal spray added to standard of care (SOC) also cleared viral loads faster in more severe ( 56) or hospitalized cases ( 58, 59). In a dose-finding study done in COVID-19 outpatients with pneumonia without ARDS, regular SI (20 mL every 3 h) led to more patients becoming PCR-negative on Day 5 than controls (68 vs. 25%; P < 0.05) ( 56). As further discussed under Section 3.3.3, this was associated with improvement in SARS-COV-2 pneumonia. Nasal SI resulted in significant earlier clearance in hospitalized patients for Omicron infection ( P < 0.05) ( 59). Hypertonic nasal spray use was found to reduce significantly the nasopharyngeal viral load during the initial treatment days when used add-on to hydroxychloroquine vs. hydroxychloroquine alone ( P = 0.019) ( 58).

3.1.2.4. Salivary and mid-turbinate loads

Salivary or mid-turbinate viral load reductions, obtained with saline nasal spray or SI, were not significantly different between saline and antiseptic comparators (mouth rinse or nasal spray containing polyvidone iodine, chlorhexidine, or detergent) ( 48- 50, 53, 60, 61). Short (15 s) hypertonic saline gargling three times daily did not render mild patients getting faster negative in the PCR test (sampled by nasal and oropharyngeal swabbing) than their controls (median 9 days), despite significant symptom recovery with saline only (Day 4, P < 0.04) ( 53). These data suggest that oronasal SI or the combination of nasal rinse and gargling may achieve the highest effect.

3.1.3. Viral replication inhibition in vitro

Saline (0.9-1.3% = 150-200 mM) has been reported to reduce viral replication by 50-98% in vitro, thereby reintroducing voltage-gated depolarization in the infected host cells ( 63). These concentrations also reduce the activity of furin, a human protease, hijacked by SARS-CoV-2 for cleaving the unique furin cleavage site in its spike, thereby priming the spikes for cell fusion ( 64), and involved in its virulence ( 65). Furin is highly expressed in salivary glands and present in saliva, and it has been proposed to induce virus pre-activation, which could favor prompt spread through saliva droplets of more infectious virions than those through sneezing and coughing ( 66, 67). Saline at these salt concentrations also impairs 3CLpro (Mpro), a SARS-CoV-2 protease regulating replication ( 68). These modest effects may be relevant to combining nasal SI with protease inhibitors to reduce relapse with latter antivirals ( 62, 69).

3.1.4. Effects on exhaled viral load/bioaerosol

As reviewed ( 70), NaCl has unique ionic properties leading to droplet/vesicle aggregation, optimal viscosity, and properties of mucus and reduced bioaerosol. Faster hygroscopic growth of iso-/hypertonic bioaerosol and mucus droplets due to saline leads to earlier deposition in nasopharynx/airways, while these particles will be removed continuously from the airways via the mucociliary clearance and be swallowed, and so limits penetration of pathogens in the deeper airway and lungs ( 71- 73). In line with these unique ionic properties of saline, nebulizing saline was found to reduce exhaled droplet numbers in bioaerosol superspreaders ( 74), while in hospitalized COVID-19 patients, the continuously sampled bioaerosol during 0.9% saline nebulization was found to be devoid of SARS-CoV-2 RNA or live virus: In contrast, nebulization of viral culture, equivalent in titer to the sampled nasopharyngeal load of these patients, resulted in positive bioaerosol samples ( 75). So, there is no evidence of dissemination by the aerosolizing/nebulizing procedure. It is interesting to note that in a study of 12 hospitalized qPCR-positive patients, nasopharyngeal viral loads (sampled following a 20-mL saline gargle to generate baseline values before H ₂O ₂ assessment) were low, with only five in 12 showing loads expected to contain viable virus, while intriguingly upon culturing, only one viable out of the five ( 76). The relevance of these observations deserves further study, whether due to the sampling method, or saline rinse effects [such as diluting and/or aggregating virus, reducing furin-mediated priming, and/or deactivating virus via salivary myeloperoxidase (see Section 3.2.3)]. Facial mask impregnation with salt/saline has been found to lead to better filtration or deactivation of virus ( 70, 77).

3.1.5. Reduced transmission and prophylaxis

Overall, publications on the prophylactic use of SI in COVID-19 are limited so far ( n = 5). One study relates to SARS-CoV transmission ( 78), and three sources were related to SASR-CoV-2 transmission, during the initial ( 79), Alpha-Delta ( 80), and omicron wave ( 59), while one more experience was solely reported in the press (therefore not tabulated) ( 81). One randomized study used local saline brands containing minimal amounts of chlorine (nose rinse spray and mouthwash) in healthcare workers (HCWs) during the first COVID-19 wave ( 82) (For details, see Supplementary Table S4, p. 17).

An earlier randomized trial assessing SI for common colds reported a 35% reduction in household transmission of respiratory viruses, including human coronavirus, compared with controls ( 8). In line with this controlled study, a prospective study of SI in COVID-19 patients found limited household contacts testing positive after SI (12.7%) ( 80); expected rates for within-household transmission average 18.8-27.0% (range 4.6-90%; for the original variant) ( 83, 84) and 15-35% according to a large UK study (Alpha variants are 50% more infectious than wild-type while 35% less infectious than Delta) ( 85)-(relevant to this study, run 24 September−21 December 2020).

Successful prophylaxis has been reported in HCWs using SI adjunctive to personal protective equipment (PPE), during initial ( 79, 82), Delta ( 81), and Omicron waves ( 59). This beneficial effect of nasal rinsing was already observed during the first SARS-CoV wave ( 78). A significant reduction was found in an initial randomized prophylactic study with electrolyzed SI (nose rinses and mouthwashes), resulting in 12% HCWs becoming infected with saline prophylaxis and 12% without ( P < 0.05) ( 82). An Indian press report reported similar protection rates during the Delta wave (no study details available): 1% of HCWs using daily SI became PCR-positive compared with 10% in the wards not using SI ( 81). A COVID-19 designated hospital in China recently reported zero Omicron infections among HCWs in a large COVID-19 designated hospital in Shenzhen (1,930 COVID-19 patients admitted during Omicron peak), all obliged to use daily SI add-on to strict PPE wear ( 59).

Indirect support for SI and nebulization in reducing transmission also comes from an ecological regression analysis, finding that highly populated coastal areas with high concentrations of atmospheric salt recorded significantly fewer COVID-19 infections and deaths per capita compared to inland regions by 25-30% ( P < 0.05) ( 86).

3.2. Mucosal NaCl homeostasis and innate immune response

3.2.1. Modulation of ion channels and homeostasis in the mucosa

A commonly overlooked effect of SARS-CoV-2 infection is the impairment of ENaC (sodium channel) activity by SARS-CoV-2 and its S and E proteins, likely due to the virus competing for and so hijacking furin, a ubiquitous human protease activating ENaC ( 63, 87). They silence the cell membranes, eliminating voltage-gated transmembrane potentials and depolarization, so impairing Na⁺-influx and fluid reabsorption ( 63, 87). This leads to a complex dysregulation of many processes requiring salt gradients or ion transport, some of which are discussed below, others are beyond the scope of this article: For instance, ENaC is the driving regulator of airway surface liquid and mucosal hydration, ciliary motion, mucus transport, and reabsorption of airway and alveolar secretions; beyond the respiratory tract, ENaC also (co)regulates taste buds, ACE2, systemic hemodynamic, and immune responses ( 88- 90). As saline re-introduces depolarizations and so restores Na⁺-influx in infected cells ( 63), SI may help to modulate or limit ENaC-associated dysfunctional processes in the respiratory mucosa.

3.2.2. Improved mucociliary clearance, mucus, and cough clearance

SARS-CoV-2 infection has been shown to impair MMC in SARS-CoV-infection ( 70, 91), which often causes nasal obstruction and dry cough ( 92). Established actions of iso/hypertonic SI in other respiratory diseases include hydration of the periciliary layer and improving MMC and cough clearance ( 70). These properties may contribute to faster SARS-CoV-2 clearance (see Section 3.1.2.). Saline profoundly changes the viscosity/elasticity of mucus and adhesion/cohesion of mucins, both hydrating and gelling/ thickening these toward easier transportable mucus ( 93- 95). Moreover, the mucus production, stimulated by interferon-aryl hydrocarbon receptor signaling in SARS-CoV-2 infection, would trigger the hypoxia of COVID-19 ( 96). As mucus plugs (often combined with neutrophil extracellular traps (NETs) in COVID-19, see Section 3.2.3.) create local hypoxic environments that can contribute to enhanced secretion of destructive neutrophil granule contents ( 97), mucus removal by early SI may help to reduce and prevent nasal and airway obstruction and its deleterious consequences. Postnasal drip, nasal obstruction, cough, and sneeze are relieved by SI in mild-to-moderate COVID-19 (see Section 3.3.1.).

3.2.3. Dampening neutrophil elastase activity

One of the altered immune responses in COVID-19 involves excessive neutrophil activity and NET formation, which is already observed (also nasally) early in the disease ( 98) and has been implicated in the development of acute lung injury, the induction of the SARS-CoV-2-induced cytokine storm, ARDS, and immuno-thrombosis ( 99, 100). NETs are composed of decondensed chromatin fibers coated with antimicrobial proteins, such as myeloperoxidase (MPO) and neutrophil elastase, aimed at capturing and neutralizing pathogens to prevent microbial dissemination ( 99). However, SARS-CoV-2 develops more invasive cell infection and higher pro-inflammatory responses in the presence of neutrophils in vitro ( 101), while the complex actions of MPO and elastase are thought to contribute to the inflammatory damage in COVID-19 ( 70, 99, 100, 102). SI may help to clear the adhesive mucus/NETs through the simple action of rinsing the mucosal surfaces, as evidenced by the therapeutic plug removal with saline bronchial lavage or washing in COVID-19 patients ( 37, 103, 104). Other relevant mechanisms that have been observed with hypertonic SI (>200 mM NaCl; 150 mM = isotonic) in respiratory disease include lowered NET formation and decreases in neutrophil elastase activity, pro-inflammatory cytokines, and reactive oxygen species (ROS) (NaCl ion-specific effects) ( 105- 107).

3.2.4. Local virucidal hypochlorous acid production

Moreover, NaCl has been shown to inhibit the replication of enveloped and non-enveloped DNA and RNA virus in vitro, via the production of virucidal hypochlorous acid (HOCl) by neutrophil phagosomes-considered to be an innate antiviral immune response and involving myeloperoxidase, thereby also providing a mechanism for oxidative NET-mediated microbial killing ( 70, 108- 110). HOCl also controls neutrophil elastase activity and NET release ( 109, 111), so representing additional mechanisms by which saline may act to limit the illness progression. The role of this innate immune process in the inactivation of the virus [a study finding low infectivity of saline gargles from COVID-19 patients ( 76)] deserves further study, as myeloperoxidase activity is markedly increased in saliva and lungs of SARS-CoV-2 infected patients ( 112).

3.3. Clinical benefits of SI in COVID-19

Twenty-one eligible clinical (mainly small) studies were identified through PubMed and broad Internet searches (some reviewed for viral load under Section 3.1.2) ( 53- 62, 80, 92, 113- 124). They are listed in Supplementary Table S4, p. 17-29. As illustrated in Figure 4 , these studies used ample-volume (oro)nasal SI ( n = 8), repetitive saline sprays or drops (sometimes as placebo) ( n = 8), gargling ( n = 1) or nebulization ( n = 3), spanning various study designs, disease severity, irrigants or nasal spray/drop comparators, and outcomes. As many studies were small and study samples were not powered to detect differences in outcomes on COVID-19-related risks, such as pneumonia, hospitalization, ICU admission, invasive oxygen need/ventilation, and mortality, the latter results are consolidated in Supplementary Table S5, p. 30.

3.3.1. Respiratory symptom reduction

In a non-randomized case-controlled study, newly diagnosed COVID-19 patients, starting immediately isotonic SI once daily after PCR testing, experienced significantly more nasal symptom relief than controls ( p < 0.05) ( 54). In addition, other studies comparing to controls have reported significant symptom recovery, reduction of postnasal drip, nasal obstruction, cough, or sneeze ( p < 0.05) ( 53, 113, 114, 116, 121).

In a prospective study, PCR-positive patients older than 55 years (mean age 65 years), mostly with high BMI, were assigned to two different pressurized SI techniques ( 80). COVID-19 symptoms (loss of smell or taste, fatigue, fever >100.4°F, chills, muscle aches, runny nose, new onset (or worsening of chronic) cough, shortness of breath, nausea or vomiting, headache, abdominal pain, and diarrhea) were resolved after 14 days of SI in 63 of 71 participants (one hospitalization, see Section 3.3.3); symptom resolution was more likely for those reporting twice daily SI than once ( P = 0.0032) ( 80).

Studies with nasal spray or drops comparing symptom relief with saline (as placebo) and various treatments (polyvidone iodine, calcium chloride, and ciclesonide) have not reported the superiority of SI, though they have shown symptomatic improvement consistent with the comparators (see Supplementary Table S4, p. 20_22) ( 53, 60, 80, 92, 115).

3.3.2. Smell and taste recovery

Symptoms of smell or taste dysfunction in COVID-19 patients may take 10-40 days to resolve with SI ( 54, 61, 80, 113, 116- 120). For specific studies in COVID-19 patients with smell and taste disturbances, see Supplementary Table S4, p. 23 (studies in long-COVID-19 patients were excluded). Overall SI and nasal steroids were found to perform equally well (no consistent statistically significant differences) ( 118- 120). Yet, a significantly faster resolution was obtained with the combination of SI and triamcinolone, a finding that needs confirmation in larger clinical studies, while at best also evaluating the impact of frequency of SI ( 120).

3.3.3. Hospitalization and intensive care risks

3.3.3.1. SI or spray use

Although not set as primary outcomes, except for two studies ( 80, 113), many studies using SI or saline spray reported on the rate of hospitalizations, some ICU outcomes, and mortality. Overall, the studies were too small to detect significant differences. For tabulation of these outcomes, see Supplementary Table S5, p. 30.

If hospitalizations were observed, rates were generally lower with the saline formulations than with controls or comparators. Relevant to patients aged 55 or more years, Baxter et al., assessing hospitalization as a primary parameter, recorded one hospitalization [1/78 (1.3%)] (no deaths) with isotonic SI in this age group with high BMI: These rates were 9.5% (plus 1.5% deaths) in a nested control population over 50 years, over the same period ( 80). Another study in COVID-19 patients during the first wave found unexplained high hospitalization rates in both groups, yet lower with SI users, but not significantly reduced vs. controls ( P = 0.66), while there was no high adherence to the rinse procedure ( 113).

In line with faster clearance of viral loads and so reduced risk of micro-aspiration from nose to lungs (see Section 3.1.1.), patients with COVID-19 pneumonia (without ARDS) experienced a significant reduction in computed tomogram-evaluated pneumonia severity score after 5 days of isotonic SI compared with controls ( P < 0.05); also the percent of patients worsening (8.8%) was lower when compared with controls (36.4%; P = 0.028) ( 56). In line with these results, another randomized study of isotonic SI, initiated in hospitalized COVID-19 patients and leading to faster viral clearance Day 2 ( P < 0.02), suggests that rapid initiation of SI following a positive PCR test may help to lower subsequent need for oxygen administration, ICU admission, and mortality, although the differences did not reach statistical significance between the small patient groups ( n = 25 per group), and a potential bias may have incurred by the average older age of the control group ( 51).

3.3.3.2. Nebulization

Two prospective and one randomized hospital studies used nebulized saline adjunctive to SOC ( 122- 124). In patients with ARDS, saline nebulization (+ibuprofenate) ( 123) was associated with improved respiratory rate ( 123), low need for invasive oxygenation or intubation ( 122, 123), and low(er) mortality (compared to controls) ( 123, 124). These findings are in line with observations in patients with bronchiolitis and other respiratory diseases, in whom iso- or hypertonic saline has been shown to improve oxygen saturation ( 125, 126).

In a four-arm study in ventilated patients with ARDS comparing two solutions vs. saline 0.9% and controls (twice daily), methicillin-resistant Staphylococcus aureus incidence significantly decreased with the nebulizing treatments vs. controls (12% for saline vs. 34.6% among controls; P < 0.05); mortality was lowest among the patients receiving nebulized saline (40.5 vs. 59.6% among controls; not significant) ( 124).

In line with the findings on bioaerosol, following saline nebulization in hospitalized COVID-19 patients ( 75) (reported in Section 3.1.4), nebulization was reported not to lead to transmission or spread of the virus among HCWs ( 122).

In conclusion, studies in COVID-19 patients have consistently reported safe use and outcomes favoring SI use in COVID-19, whether it was used as sole intervention initiated immediately after positive PCR testing in mild-to-moderate COVID-19, or as part of the patient treatment protocol adjunctive to SOC in an ambulatory setting or upon hospitalization. The results require confirmation in large, randomized studies.

3.4. Patient satisfaction and risk

This review found that SI is accepted and well-tolerated in all studies reported. Nasal burning or discomfort was reported consistent with other reports and clinical practice. These can often be ameliorated by reducing salinity and technique adjustment. Epistaxis is rare and was not reported in reviewed studies, except in older individuals ( 80). Nasal SI requires the use of clean water, as rare infection, and death with N. fowleri has been reported ( 127).

Concerns for SI affecting the blood pressure adversely have not proven to be a problem, as has been evidenced in patients with chronic lung disease, also at hypertonic concentration ( 128, 129). Patients should be advised not to swallow saline drip or gargles but to spit these out safely in a sink or receptacle.

Daily use of repeated SI may show lower compliance in vulnerable patients, such as those admitted in care homes with COVID-19. This challenge can be overcome by motivating home residents and staff to apply SI and survey the significant reduction in respiratory complications ( 130). SI materials (Neti pot and squeeze bottle) should be cleaned daily. Routine precautions for limiting the COVID-19 spread remain essential.

4. Discussion and lessons learned

While it is acknowledged that a short 30-s contact of saline with the SARS-CoV-2 virus does not exhibit direct virucidal activity ( 131), this narrative review on SI revealed that nasal SI performed repeatedly for 1 day may lead to a significant reduction in nasopharyngeal virus load, while a repeated application for 7-10 days leads to faster viral clearance. Overall, patients with positive swab tests experienced substantial viral load reduction, became PCR-negative faster, and had milder symptoms than untreated patients. Hence, repeated application of SI can be recommended for fastening viral clearance, symptom relief, and prophylaxis against respiratory infection, as has been increasingly proposed in (self-care) treatment or hygiene prevention guides for COVID-19 ( 9- 13, 15, 59, 70, 79, 132- 134).

Albeit found to significantly relieve symptoms in the study ( 53), and in line with pathophysiology (infection starting in the ciliated nasopharynx), short daily hypertonic saline gargling in COVID-19 patients did not fasten the SAR-CoV-2 nasopharyngeal clearance. In view of the low rate of live virus in gargle samples so far assessed in one study ( 76), larger-scale, well-validated studies are desirable to appreciate its potential role in reducing salivary loads and transmissibility in patients with COVID-19.

In the studies reviewed, both isotonic and hypertonic SI (1.5-3%) were used and found to be safe and effective for nose and throat irrigation in COVID-19, when administered with mildly pressurized flasks or devices, using protocols similar to those established in other respiratory diseases ( 5- 13). Regular daily application of SI volumes, twice daily up to every 3 h rather than once daily, may enhance outcomes, as was observed in COVID-19 with comorbidity ( 80) or pneumonia ( 56).

Our evaluation of the mechanisms of saline and clinical studies suggests that saline may act more than placebo, similarly as previously proposed in other respiratory conditions ( 135, 136). This action may deserve attention in studies of nasal steroids, using saline drops or spray as comparator: A recent Cochrane analysis on the prevention of olfactory dysfunction was unable to conclude their efficacy ( 137). Whether combinations of saline with anti-inflammatory agents or corticosteroids provide extra-benefits over saline alone needs further study.

4.1. Additives

Overall, our data did not indicate a rationale for (antiseptic) additives to oral or nasal saline for daily oronasal hygiene (no significant intergroup differences) ( 46, 48- 50, 53, 60, 61, 80). Possibly, the effect of additives may diminish fast due to salivary clearance ( 138). Many substances have been proposed for the development of nasal sprays or mouth rinses in COVID-19 ( 139). Bias through direct interaction with the PCR test by the additive should be excluded (see Supplementary Appendix A, p. 05, point 4). This is not a problem with saline which, in contrast, is used as a common PCR test sampling fluid.

4.2. Controversies and risks

Contrary to concerns that SI may cause harm through postnasal drip or contamination from nose to throat, respiratory tract, or olfactory bulb through viral movement or micro-aspiration ( 140- 143), this review does not find evidence of such a risk. Moreover, this review did not find evidence for an increased hazard to contaminate or transmit SARS-CoV-2 through the use of nebulized saline for COVID-19, in the context of healthcare or household settings. The findings that viable virus is absent in (exhaled) bioaerosol during saline nebulization ( 75), and that transmission was not a problem during the clinical experiences with inhaled saline ( 121- 124), support the guidance of authorities that encourage nebulization to be used or continued during COVID-19 ( 16). They also make nebulization of saline an acceptable alternative in (older) patients unable to perform SI. In Germany, pneumologists have acknowledged the effects of SI on bioaerosol since the start of the pandemic ( 132) and have encouraged patients to nebulize saline solution against COVID-19 ( 144). So, the use of SI or nebulization in the hospital or at home should not be discouraged, and this synthesis may help to inform authorities to adapt and/or adopt this hygienic measure.

Although data on SI for COVID-19 are far from complete, the results of this review show that there is solid translational evidence that for COVID-19, SI is unlikely to harm and likely to help. It is, therefore, reasonable, indeed ethically necessary, for authors of published and online news or recommendations on saline to amend erroneous claims suggesting harm for its use in COVID-19, for example ( 13, 140- 143). The WHO has already taken this step by deleting SI from the Mythbusters webpage ( 14).

4.3. Limitations and developments needed

Most studies were small and of substantial heterogeneity, so bias cannot be excluded. However, given the overall robust in vitro and in vivo effects of nasal and oral SI, and the emerging evidence from observational and randomized studies (irrespective of saline being the object or reference/placebo), both health authority support and institutional funding are needed to design and perform large, randomized trials to formally test SI when implemented as an adjunctive preventive and treatment modality for COVID-19.

Yet, as SI use appears to be safe and is already practiced for common colds and viral upper respiratory infections ( 5- 8), current evidence suggests that SI can be recommended as a public health measure along with other routine hygiene measures, albeit with strict attention to clean water and washing of SI materials. This is corroborated by experience with SI in COVID-19 in a hospital in China ( 59) and by a recent consensus of Chinese experts in otorhinolaryngology ( 15).

4.4. Practical recommendations

As an efficacious measure particularly if early started in COVID-19, SI can be effectively implemented at every age in those with positive SARS-CoV-2 test. We recommend its regular use as needed, up to 2-3 days after resolving symptoms, with a minimum of 10 days of repetitive saline nasal irrigation and gargling and repeated up to every 3 h in case of moderate COVID-19/pneumonia. Ideally, nasal irrigation and gargling are combined, as both nose and throat can be affected, and are started as soon as common symptoms develop and/or COVID-19 positivity is diagnosed. Larger well-standardized, randomized research trials may help to determine optimal volume, pressure, and salinity. Based on our analysis and the broader Chinese hands-on experience ( 15), any concentration between 0.9 and 3.0% appears to be suitable, while large, repeated volumes are preferred. For prophylaxis, several protocols have been suggested for use as part of the post-exposure or preventive protocol ( 15, 59, 70, 79), which can be all-inclusive (washing hands/face and saline eye rinse, nasal irrigation, and gargling), thereby aiming at covering all sites of viral entry or attachment ( 79). For video instructions how to make or apply SI at no cost, three links to video instructions are found under Supplementary Table S4.

5. Conclusion

Overall, substantial evidence was found in vitro and in vivo in support of SI use in COVID-19, also emerging from observational and randomized studies irrespectively of saline being the main intervention or reference/placebo in the study. As an international network of investigators with substantial clinical and research experience in saline use for several respiratory diseases and SARS-CoV-2 infections, we, therefore, propose to include rinsing the nose and throat with saline as an early intervention to prevent, and relieve symptoms of, SARS-CoV-2 infection: It is easy-to-use, inexpensive, safe, and feasible at every age. Considering the current high SARS-CoV-2 mutation rate and COVID-19 waves less responsive to population-based immunization, the recommendation to use nasal and oral saline irrigation is adjunctive to current biologicals and therapeutics, as well as to protective interventions, such as mask wear, social distancing, and hand hygiene. We also advocate for health authorities to dedicate further research funding to further clarify the preventive and therapeutic role of saline irrigation for SARS-CoV-2 infections at a global level.

Author contributions

All authors of this Pro Bono Initiative, started by informal contacts per e-mail and Zoom, had pharmacological and/or clinical experience with saline irrigation in COVID-19 or related respiratory conditions. All the authors contributed by their knowledge, specific (pre)clinical research, or experiences (see reference list). Manuscript development occurred through the submission of work or description and discussion of mechanisms by e-mail and by Zoom meetings inviting all network members and coordinated by SH, SP, and DR. For completeness of the review, continuous searches for additional data were performed and new data were circulated by SH, while interpretations and problem-solving, development of lessons learned, and recommendations occurred through e-mail and discussion at the regular Zoom meetings. Integration of changes in the manuscript and revisions thereof were coordinated by SH, while regular feedback by e-mail to the Network and recirculation of the manuscript. All authors contributed to the development of consolidated knowledge, conception, and/or interpretation and helped in critical revision and resolving questions at each circulation until final consensus for submission. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

5. International Pharmaceutical Federation (FIP) . Cold, Flu Sinusitis. Managing Symptoms Supporting Self-care. A Handbook for Pharmacists. (2021). Available online at: https://www.fip.org/file/5089 (sccessed November 5, 2022).

7. Ao H, Wang Q, Jiang B, He P. Efficacy and mechanism of nasal irrigation with a hand pump against influenza and non-influenza viral upper respiratory tract infection. J Infect Dis Immun. (2011) 3:96-105. [ Google Scholar]

15. Yu S, Yang Y, Xu Y, Meng J, Zuo K, Wang H, et al.. Chinese Rhinopathy Research Cooperation Group. Expert consensus on nasal saline irrigation for the prevention of SARS-CoV-2 infection. Chin J Ophthalmol Otorhinolaryngol. (2022) 22:329-34. [ Google Scholar]

95. Charriot J, Volpato M, Petit A, Vachier I, Bourdin A. Methods of sputum and mucus assessment for muco-obstructive lung diseases in 2022: time to "unplug" from our daily routine! [[ Cells. (2022) 11:812. 10.3390/cells11050812 PMC free article] [ PubMed] [ CrossRef] Google Scholar]

142. Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied . Neusspoelen en Covid-19. KNO (Official Site of Dutch Ear-Nose-Throat specialists) (2020). Available online at: https://www.kno.nl/neusspoelen-en-covid-19/ (accessed September 28, 2022).

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Bonus points if you read everything in full & help get the word out. If folks need things read out loud, DM us for an audio recording!
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REMOTE: petition links, call scripts & more at celebrate845.com/FreePalestine (in bio). BOTHER EVERY ELECTED. The system isn't meant to liberate. No justice, NO peace. 
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WED 02/05 @ 1PM: rally at Bard College via @bard_sjp . Access info in slide 3!

SATURDAYS @ 12:30 @ Elting Library, New Paltz: Women In Black. Outdoors on thin busy sidewalk. Areas to sit. Street parking metered, free on side streets (past the library parking lot). No chants, v chill!

SUNDAYS @ 12-3PM in Beacon. Access info in slide 8!

SUNDAYS @ 12PM in Woodstock. Outdoors on sidewalk near flatter stone park. 

SUNDAYS @ 1PM in Nanuet. Outdoors w/ chants on wide sidewalks by busy road. Park @ Shake Shack! By Rockland For Ceasefire.

ALL DAYS: go add to the community altar on the fence at Hasbrouck Park, New Paltz!

ALL DAYS: working with @peoplesppe to give out FREE KN95 face masks! Please reach out to help distro or get masks.

ALSO plz reach out if you wanna collab on direct actions!
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Another world is HAPPENING- be part!

Know your rights & practice mutual aid!

MASK UP. Over 2K people are passing weekly from COVID. The revolution MUST be intersectional. We can't show up when we're sick. Let us provide FREE MASKS at upcoming things!

& send over any other upcoming actions / PLEASE include accessibility info. We need it! Use the checklist in our bio.

Organize, amplify, attend, recharge ♾️ gratitude to those who continue to do their part. A million roles to pick from. Ask us how to plug in - we need you!

IDs in comments"

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A number of people have reached out recently to ask about this group. I may be able to start another group in March if there's a time that works for enough people. If you're interested fill out this poll with what times work for you. I'll email you by February 21st to let you know if that group is going to get started.

This is a by-donation facilitated, online, peer-support group for people negotiating continued safety measures in the face of the unfolding pandemic.

Why these groups exist

Governments, the medical system, and most of the general population are treating COVID as inevitable and a matter of individual responsibility. Those who continue taking precautions against infection are increasingly isolated as we watch most people go back to normal daily life.

The goal of this group is to create a space where people who continue to proactively protect themselves from COVID don't have to explain or defend themselves. We can share sorrows, fears, and frustrations as well as resources, strategies, hope, and mutual support through open dialogue.

This group actively welcomes members of all races/ethnicities, gender identities, socioeconomic realities, and varied spiritual/religious beliefs. The group welcomes able-bodied, disabled, and/or immunocompromised folks. The expectation is that we come together to try to hold each other's diverse experiences with mutual respect. This is a place to think about what you need from others as well as what you have to offer.
Please note: This is not a psychotherapy group - this is supplemental peer support and does not take the place of any formal mental health services. Anyone who wishes to apply who is in need of psychotherapeutic support is encouraged to seek it out and have it in place before applying for this group. Additionally, nothing in this group should take the place of professional medical advice.
Time and Place

This is a ten session group that meets every other week via Zoom. Each session is 1 hour and 15 minutes long.

Group Size

10-12 members

Donations

The standard donation is $25 per session, or as determined by your financial situation. What you donate is based on your own assessments of your budget and investment in the group. Donations are entirely on the honor system.

Payments can be made via Venmo, PayPal, or my website.
Note: This is not a psychotherapeutic service and as such will not be reimbursed by your insurer.

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Still COVIDing Peer Support - Wilde Therapies

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A facilitated, shared support space for those who are still COVIDing.

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CripCreate, A weekly online co-working space by and for all Deaf and Disabled people. This is a Disability Justice-centered co-working space for all Disabled (sick, Disabled, Mad/mentally ill, Deaf, Hard of Hearing, low vision/blind, neurodiverse, or otherwise chronically ill) people.

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With the holiday season well underway, here is an update on the current COVID situation as well as tips for making your holidays and winter safer using multilayered precautions.

Ongoing COVID viral spread is apparent in the CDC's latest wastewater map, with high or very high levels across almost two thirds of states and territories in the US. Out of 54 total states and territories, 35 showed high or very high COVID wastewater levels as of 12/9/2023. It's clear that multilayered COVID precautions are warranted.

Wastewater surveillance is a useful tool, but it also has its limitations. If you are living in a state with low or minimal wastewater levels (or insufficient data), do not take the comparatively lower levels as a reassurance of safety. We do not know what these levels translate to as far as the risk in our daily lives, and viruses do not respect state (or national) boundaries. Variability in sampling, number of testing sites, and other factors mean that data may not necessarily be comparable between different locations.

Local wastewater dashboards may give you a more detailed view of the situation in your area, or in areas you may be visiting. An example from Wisconsin is shown below.

On 12/14/2023, the CDC issued an alert reporting increased respiratory disease activity for winter 2023-2024, including increases in COVID, RSV, and influenza rates. The CDC's alert encourages increased vaccination and use of FDA-approved treatment options. I strongly recommend up-to-date vaccination for everyone who is eligible, as well as use of treatment options (Paxlovid is discussed below). Despite their effectiveness, vaccination and treatment still cannot guarantee a mild illness or a full recovery from COVID. We must prevent COVID spread through multilayered precautions, including masking, testing, ventilation/filtration, and physical distancing.

COVID continues to pose a significant threat to both individual health and public health, with COVID being the 4th leading cause of death in 2022, behind only heart disease, cancer, and unintentional injury. It is now well-proven across multiple studies that COVID causes damage to many organs throughout the body and causes Long COVID. As you continue or restart multilayered precautions to avoid COVID this winter, know that you are well-supported by scientific evidence.

Whenever people gather, there is a risk of COVID transmission. Taking multilayered precautions can drastically reduce the risk. The more precautions everyone at the gathering can collectively take, the better. One-way masking is better than not masking at all, but universal masking, improving indoor air quality with ventilation and filtration, and other group actions will have an even greater impact in reducing the risk. No one wants their holiday gathering to become a super spreader event!

It is always OK to decline an invitation to a social event if it doesn't seem safe. Healthy relationships are built on mutual care and respect for each other's boundaries.

The safest option, which I personally use regularly, is virtual options for meetings and gatherings. Whether we use them for daily casual conversations or larger celebrations, virtual options are a fulfilling way to keep in touch with loved ones without the risk of spreading COVID. Remote options ranging from snail mail to phone calls and video calls also help us stay connected across long distances. Virtual options can expand our social connections beyond the people we might see in person in our daily lives.

If you choose to travel, wear a well-fitting mask (N95-equivalent or better) throughout your travel, including on planes, buses, trains and in airports or other transportation hubs.

If you need to remove your mask to eat or drink, try to do so in a safer spot such as outdoors or away from people, and minimize your time unmasked if there is shared air. Just in case, bring extra masks, as well as COVID tests and other basic hygiene supplies such as hand sanitizer.

Prepare as best you can for the possibility of delays and cancellations. If possible, plan your trip so you might have safer options for meals and sleeping arrangements. When you return home, additional precautions (from masking up to quarantine) are worth considering around any household members who didn't travel.

Holiday shopping and even routine activities like grocery shopping pose extra risks this winter. When possible, use shipping, curbside pickup, or delivery options to reduce exposure. If you must go inside a store, keep trips short and wear a well-fitting mask.

Workplaces also present increased hazards as workers may not be provided appropriate paid sick time to stay home when ill. Masking, using portable HEPA air purifiers, and using work-from-home options when available can help reduce your risk.

If, despite your best efforts, you develop a COVID infection, Paxlovid is recommended as COVID treatment to prevent severe disease. As an added bonus, Paxlovid also reduces the risk of developing Long COVID by about 26%. Most Americans (75%) have an underlying condition that places them at higher risk for severe COVID, which should qualify them for Paxlovid prescription after consultation with a healthcare provider. These conditions include diabetes, high blood pressure, being overweight, pregnancy, anxiety, and depression, among many others.

Test-to-treat options are available, although they vary by state/location. There is a free Home Test-to-Treat program for patients who are uninsured, rely on Medicare, Medicaid, or VA insurance, or receive care from Indian Health Services. In Wisconsin, the telehealth option for COVID treatment was extended and continues to be available through April 10, 2024. Pricing and insurance coverage for Paxlovid will be changing as it transitions from the government supply to the commercial market in December 2023.

Here are just a few of the things I do not recommend for COVID treatment or prevention: nasal sprays, mouth washes, eye drops, or supplements. So far, none of these have been well-proven to be safe and effective for COVID treatment or prevention, and none are approved by the FDA. Although some of these approaches seem innocuous enough at first glance, they can cause harm and may cause a false sense of security. Be vary wary of claims made about over-the-counter products or products that can only be purchased from international pharmacies. Counterfeit and adulterated products are also a concern; unfortunately, supplements and over-the-counter remedies are not tightly regulated in the US. Large-scale clinical trials are needed to show that any drug or supplement is both safe and effective. Regardless, there is no substitute for proven layers of protection. There is much more to say on the topic of unproven methods, but I hope this helps for now.

I hope all of you have a happy and safe holiday season. 😷🎉

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Multilayered precautions help prevent uninvited viral guests this holiday season and beyond

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Community Support for Long COVID by Body Politic 

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Community Support for Long COVID by Body Politic 

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+ I'm a patient, how do I join?

The following individuals are welcome in our support group:

people experiencing COVID-19 symptoms

people who previously had COVID-19. This includes people who suspect they had COVID-19 but could not access testing

people recovering from COVID-19 or experiencing symptoms after COVID-19

people who have tested positive for COVID-19 (you do not have to have a positive test to join the group!)

caretakers and immediate family of COVID-19 patients who are currently too sick to actively participate in the group

To join, please fill out the form linked above on the button labeled Join the Group. We just need to know a little bit about what you're going through to verify that you're a real person in need of support, but all information you share on that form is private and will only be accessible to admins of the group. Please use our resources page and check out our past events for educational resources on Long COVID.

+ What is the Body Politic COVID-19 Support Group, and how did it form?

Body Politic started the COVID-19 support group after Founder and EIC Fiona Lowenstein, and Creative Director Sabrina Bleich became sick with coronavirus in early March. After falling ill, we quickly realized that there was not enough online content or resources dedicated to people struggling with coronavirus. As we scrolled through Instagram feeds filled with tips on navigating boredom during quarantine, or how not to catch the virus, we felt increasingly isolated, misunderstood, and ignored. With news of infection rates rising, we knew a community of people like ourselves existed, and was growing - we just needed a way to reach each other.

We launched the Body Politic COVID-19 support group on March 26 in a small Instagram group chat. During those early days, while Fiona and Sabrina were still navigating acute physical symptoms, our incredible Operations Manager and ally, Lida Rubanava, stepped in to help us develop the group - she's been an indispensable member of the support group admin team ever since. Since our launch, we've had over 25,000 people sign up to join our patient-only support group (which currently houses over 12,000 members) and our Ally Support Network. We have migrated platforms to Slack to accommodate the growth and allow for small discussion channels based on community or topic. Our group consists of people from all over the world who have tested positive, are experiencing symptoms, or are recovering from COVID-19. Our discussion groups includes 50+ channels for based around different communities and topics. Some of our channels include one for those symptomatic for 30+ days or 90+ days, caretakers of sick friends or relatives, those who have recovered from being on ventilators, those experiencing known and lesser known symptom groups such as respiratory, neurological, GI, and others, and forums to discuss mental health, financial and employment concerns, medical advocacy, along with many others.

+ How can I help, if I'm outside the COVID-19 community?

The most impactful way to help is to DONATE & RAISE MONEY for one-time or recurring monthly tax-deductible donation via our fiscal sponsor Springboard HealthLab, EIN 87-1818608, 5601 Van Fleet Ave, Richmond, CA 94804. Include "Body Politic" in Paypal note or check memo. Funding to support our operations allows us to keep the support group running. Our support group is completely free and open to anyone with a history of COVID-19, but our operating costs are not free. We need your monetary support so we can continue supporting people living with Long COVID in the US and internationally.

Other ways to get involved:

Request to join our Ally Support Network. We are especially interested in hearing from healthcare providers, wellness practitioners, lawyers, activists, and others with relevant experience in healthcare, chronic illness and disabilities, health justice, and emerging infectious diseases.

If you are a researcher who wants to share your study or partner with us, please reach out to info@wearebodypolitic.com. We will review survey submissions and research opportunities to share with the support group as appropriate.

Are you affiliated with a company or non-profit that can support this work in some way? For more information on partnerships, email info@wearebodypolitic.com with a short description of your organization or brand and how you would like to collaborate.

Provide a discounted service to our community. Are you a therapist, yoga teacher, medical professional, chef, or someone who provides a service that you think would be helpful for our community of sick and recovering people? Email info@wearebodypolitic.com and we'll determine if it's a good fit to share.

Apply to be a support group moderator. As our support group grows, we will need more moderators to manage conversation flow, and make sure members are following the groups' rules and guidelines. Email info@wearebodypolitic.com, and we can tell you more about this opportunity.

If you are a reporter, please reach out to PR@wearebodypolitic.com to connect with members of the group. The support group is a private space for patients and caregivers only.

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The following individuals are welcome in our support group: people experiencing COVID-19 symptoms people who previously had COVID-19. This includes people who suspect they had COVID-19 but could not access testing people recovering from COVID-19 or experiencing symptoms after COVID-19 people who have tested positive for COVID-19 (you do not have to have a positive test to join the group!)

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COVID Isn’t Going Anywhere. Masking Up Could Save My Life. by Alice Wong 

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COVID Isn’t Going Anywhere. Masking Up Could Save My Life. by Alice Wong 

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COVID Isn’t Going Anywhere. Masking Up Could Save My Life.

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“When I am in public spaces and see most people unmasked, I feel like an expendable burden not worth saving.”

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Where do we go from here? A roundtable from some disability justice organizers in this the only moment in time Leah Lakshmi Piepzna-Samarasinha 

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Where do we go from here? A roundtable from some disability justice organizers in this the only moment in time Leah Lakshmi Piepzna-Samarasinha 

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where do we go from here? a roundtable from some disability justice organizers in this the only moment in time

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where do we go from here? a roundtable from some disability justice organizers in this the only moment in time Leah Lakshmi Piepzna-Samarasinha Something I keep thinking this year is,…

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You Are Not Entitled To Our Deaths: COVID, Abled Supremacy, and Interdependence by Mia Mingus

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You Are Not Entitled To Our Deaths: COVID, Abled Supremacy, and Interdependence by Mia Mingus