SARS-CoV-2 and COVID-19 Prevention and Treatment Options

Prevention

Avoiding exposure to the SARS-CoV-2 is the best way to prevent illness. Staying away from individuals who are ill or who may have been exposed to the virus can reduce your risk of contracting the virus.¹

Washing hands with soap and water or using an alcohol-based hand sanitizer when handwashing facilities are not available can also be effective in reducing infection risk.²

Participating in physical activity can also reduce the severity of COVID-19 illness. A study published in the American Journal of Preventive Medicine in December 2022 found that exercise reduced the risk of severe COVID-19 outcomes, with researchers recommending that public health officials “add physical activity to pandemic control strategies.”^{3 4}

Mask Mandates and Evidence

In 2020, the CDC recommended the use of facemasks to prevent the spread of SARS-CoV-2,⁵ and many states and jurisdictions invoked mask mandates in indoor settings and public spaces, including schools.⁶ The CDC also imposed a mask mandate when traveling on buses, trains, airplanes, and other forms of public transportation, which was eventually struck down in April 2022. ⁷

In the spring of 2020, the National Academies of Sciences, Engineering, and Medicine conducted a rapid review of the available literature on the use of fabric face coverings and concluded that:

“There is little evidence regarding the transmission of small aerosolized particulates of the size potentially exhaled by asymptomatic or presymptomatic individuals with COVID-19. The extent of any protection will depend on how the masks are made and used. It will also depend on how mask use affects users’ other precautionary behaviors, including their use of better masks, when those become widely available. Those behavioral effects may undermine or enhance homemade fabric masks’ overall effect on public health. The current level of benefit, if any, is not possible to assess.” ⁸

Harms associated with the use of fabric masks include the reduction of tissue and blood oxygenation and the increase in carbon dioxide levels. Detoxification is also hindered by the reduction of oxygenation which can impair the immune system and cause additional psychological and physical issues. The use of cloth masks has also been found to increase the risk of infection and the spread of viral illnesses.⁹

A working paper published by the Cato Institute in November 2021 reviewed the observational, mechanistic and clinical evidence related to the use of cloth masks in the community setting to reduce the spread of respiratory infections and concluded that the data was inadequate to determine clear benefit (or harm).¹⁰

In early August 2021, CIDRAP Director, Dr. Michael Osterholm, who has also served as an adviser on President Joe Biden's COVID-19 transitional advisory board, admitted that cloth masks do little to stop SARS-CoV-2 transmission. Despite publicly acknowledging that masks were not effective, Osterholm stated that he supported their use in public spaces.¹¹

In February 2021, the CDC recommended the use of two masks to prevent the spread of SARS-CoV-2 virus.¹² This recommendation was based on laboratory simulations studies conducted by the CDC, which reported that wearing a surgical mask underneath a cloth mask improved the fit and filtration. Limitations to the study included the use of only one type of cloth and procedure mask, the lack of different combinations of masks (two cloth masks, surgical mask over a cloth mask) and the inability to generalize among differing populations such as children. Additionally, study authors noted that while the use of two masks might inhibit viral transmission, it also had the potential to cause visual and breathing impairments.¹³

On April 2, 2021, the CDC issued new mask guidance stating that the fully vaccinated could gather with other fully vaccinated persons indoors, or with the unvaccinated from one other household, unless they lived with someone who was at an increased risk for severe COVID-19. The fully vaccinated also did not need to stay away from others or get tested for COVID-19 after exposure to someone with COVID-19, unless they became symptomatic.¹⁴

The CDC updated guidance again on April 27, 2021 and continued to recommend that in indoor spaces, fully vaccinated individuals should continue to mask, wash hands frequently, cover sneezes and coughs, and follow any business or school guidelines. However, fully vaccinated persons could gather with other fully vaccinated people indoors without masks, or with unvaccinated people of any age, except when visiting someone with an increased risk for severe COVID-19, or who lives with someone at increased risk. Fully vaccinated individuals could also go outdoors without masks, except when gathering in large crowds, but they were still advised to avoid large indoor gatherings, to take precautions to protect themselves while traveling, to be vigilant about symptoms, and to get tested when they occur.¹⁵

In May 2021, the CDC announced that fully vaccinated individuals could resume activities without masking or physically distancing, except where required by law, workplace, or local requirements. Additionally, they could travel domestically without testing or self-quarantine, and travel internationally without testing unless their destination required it, and would not be required to self-quarantine on return. Vaccinated persons exposed to someone with SARS-CoV-2 were also advised that they would not need to self-quarantine or test unless symptomatic.¹⁶

After acknowledging that fully vaccinated persons could still become infected with SARS-CoV-2 and transmit the virus on to others, the CDC issued a health alert on July 27, 2021 and advised fully vaccinated people to wear a mask in indoor public settings in areas of high or substantial viral transmission.¹⁷

In addition to questions regarding the effectiveness of masks, the safety of their use, especially among children, has been called into question.

In June 2021, a University of Florida laboratory analyzed six masks, five that were worn by children between 6 and 11 years of age, and one worn by an adult, and found the presence of 11 dangerous pathogens. These included bacteria that cause meningitis, diphtheria, pneumonia, as well as parasites and fungi. Of the masks analyzed, one was polyester, two were cotton, and three were surgical.¹⁸

Another June 2021 study published in the Journal of the American Medical Association's Pediatrics, found that children who wore masks were exposed to dangerous levels of carbon dioxide. ¹⁹ This study, however, was retracted by the journal on July 16, 2021. The study’s lead author, Harald Walach, has publicly stated that “the retraction was political, because some people did not like our data.”²⁰

A retrospective study conducted by researchers in Germany which included over 20,000 children and noted the experiences of nearly 26,000 children found that masking children caused both physical and psychological harms. These harms included fatigue or drowsiness, headaches, concentration impairments, irritability, malaise, impairments in learning, depressed moods, and a reluctance to attend school.²¹

The CDC continues to promote the use of masks as a method to reduce the risk of viral transmission, and report that consistently wearing a well-fitted mask is better than not wearing one.²² Multiple studies, however, have found that masks show little or no benefit, and may potentially cause harm. ^{23 24 25 26}

In January 2023, the Cochrane Library published a review on the available literature pertaining to the use of physical interventions to reduce the spread of respiratory viruses. The authors concluded that wearing medical/surgical masks in community settings offered little to no protection against influenza-like illness and COVID-19. Additionally, the authors also found that when compared to surgical/medical masks, N95 and P2 respirators likely offered little to no additional protection against respiratory illness.²⁷

Vitamin D and Severe COVID-19 Illness

Individuals who are deficient in vitamin D have been found to be at an increased risk of severe COVID-19 disease.^{28 29} In addition to strengthening teeth and bones, vitamin D supports nervous, brain and immune system health, lung and cardiovascular function and regulates insulin levels. Ensuring adequate vitamin D levels may prevent a person from developing serious COVID-19 illness.^{30 31 32 33}

A large-scale observational study by the University of Chicago that was published in JAMA Open Network in March 2021 revealed that high vitamin D levels may be protective against COVID-19. The primary investigator noted that while the recommended dietary allowance for vitamin D is 600 to 800 international units (IUs) per day, the National Academy of Medicine states that up to 4,000 IUs per day is safe for the majority of people.³⁴

Another study published in Scientific Reports in September 2021 found that persons with low vitamin D levels were at higher risk of serious disease, increased intensive care unit stays, and death.³⁵

Additional Nutritional Information 

A review published British Medical Journal Nutrition, Prevention & Health in May 2020³⁶ stated that while there were no published nutrition studies specific to COVID-19 and SARS-CoV-2:

“Severe infection of the respiratory epithelium can lead to ARDS, characterised by excessive and damaging host inflammation, termed a cytokine storm. This is seen in cases of severe COVID-19. There is evidence from ARDS in other settings that the cytokine storm can be controlled by the n-3 fatty acids EPA and DHA, possibly through their metabolism to SPMs. This therapeutic approach has not been attempted in severe COVID-19 and warrants investigation.”

The review also stated that in general, vitamins A, B6, B12, C, E, folate and trace minerals such as iron, zinc, selenium, and copper are vital in reducing the risk of infections and supporting immune function. Ensuring a healthy diet containing these essential vitamins and minerals, or supplementing when dietary sources are inadequate, may be helpful in preventing illness. Gut health is also important in maintaining a healthy immune system. Consuming fermented foods and a diet rich in fiber can help to maintain a healthy gut microbiota.

Treatments

According to the CDC, most people who become ill with COVID-19 will not require any specific treatment. Over-the-counter fever and pain reducers are advised to relieve aches and pains associated with illness. Ensuring adequate hydration and rest are also considered important for recovery.³⁷

Early in-home treatment options have been recommended by researchers and physicians globally, however, many countries, including the U.S., have failed to recommend early treatment options. The “wait and see” approach has been criticized by many physicians who believe that precious time has been wasted when patients are told to monitor symptoms instead of being provided with potential life-saving therapeutics. Multiple treatment protocols have been utilized globally, with physicians reporting positive patient outcomes.³⁸

In February 2022, the CDC updated its guidelines to recommend that individuals with one or more underlying health conditions contact a health care provider immediately following a positive COVID-19 test as treatments may be available and early intervention was most effective.³⁹

FDA-Approved Treatments

On October 22, 2020, the FDA approved Remdesivir, for use in COVID-19 patients 12 years of age and older and who weigh at least 88 pounds. Remdesivir, an antiviral medication administered intravenously, must be given in an acute care setting such as a hospital or similar facility. The drug initially received Emergency Use Authorization (EUA) by the FDA on May 1, 2020, and clinical studies on safety and effectiveness for use in younger populations are still ongoing.⁴⁰

Developed by Gilead Sciences in conjunction with the CDC and the U.S Army Medical Research Institute of Infectious Diseases (USAMRIID), Remdesivir was initially used as a potential treatment against ebolavirus but found to be ineffective. Preliminary studies on its use in the treatment of COVID-19 report the medication to speed up recovery time by 31 percent.⁴¹

According to the FDA, one randomized, double-blind, placebo-controlled clinical trial conducted by the National Institute of Allergy and Infectious Diseases (NIAID) on recovery rates of persons hospitalized with COVID-19 reported faster recovery times in persons receiving Remdesivir when compared to the placebo group. The FDA press release noted that persons receiving the drug recovered on average in 10 days compared to 15 days for those in the placebo group.

Two additional clinical trials reported improvements in persons receiving Remdesivir when compared to the placebo, however results were not considered statistically significant. This includes one trial that looked at the drug’s effects on reducing mortality rates.

In mid-October 2020, the World Health Organization (WHO) reported that preliminary results of a larger international study found that Remdesivir “appeared to have little or no effect on hospitalized COVID-19.”⁴²

On November 13, 2020, Jozef Kesecioglu, president of the European Society of Intensive Care Medicine, stated that “remdesivir is now classified as a drug you should not use routinely in COVID-19 patients.”⁴³

A study published in the Journal of the American Medical Association (JAMA) in July 2021 concluded that:⁴⁴

“remdesivir treatment was not associated with improved survival but was associated with longer hospital stays. Routine use of remdesivir may be associated with increased use of hospital beds while not being associated with improvements in survival.”

This study was followed by another published on September 14, 2021 in the Lancet which concluded that:⁴⁵

“No clinical benefit was observed from the use of remdesivir in patients who were admitted to hospital for COVID-19, were symptomatic for more than 7 days, and required oxygen support.”

On January 21, 2022, the FDA approved use of Remdesivir in the outpatient setting for persons 12 years and older with mild to moderate SARS-CoV-2 infection who are considered at high risk of progressing to severe illness. Additionally, an EUA was issued for the drug to be used in COVID-19 positive infants weighing at least 3.5 kilograms who are considered at high risk for severe illness.⁴⁶

Remdesivir received full FDA approval for use in children 28 days and older and at least 3 kilograms hospitalized for COVID-19 or not hospitalized but considered at high risk for developing severe illness.⁴⁷ Approval of Remdesivir in infants and young children was based on an open label study of only 53 children, with no placebo control. In the study, 72 percent of children suffered adverse events, with 21 percent of serious adverse events considered to be unrelated to the medication. Three children died during the study, from COVID-19 or a pre-existing condition. Study results to support the drug’s approval have not been published, and the trial is ongoing with a scheduled end date of February 2023.⁴⁸

Treatments approved under Emergency Use Authorization (EUA)

Emergency Use Authorization (EUA) is a status given to experimental products by the FDA during a public health emergency, as defined under federal law.^{49 50}

Beginning in November 2020, several monoclonal antibodies, which are laboratory produced synthetic versions of antibodies, received EUA by the FDA for the treatment of COVID-19. These included baricitinib,⁵¹ bamlanivimab,^{52 53} casirivimab,⁵⁴ imdevimab,⁵⁵ etesevimab, ⁵⁶ sotrovimab, ⁵⁷ and bebtelovimab. ⁵⁸ Additionally, in December 2021, Evusheld, a long-acting monoclonal antibody for pre-exposure to COVID-19 illness, was issued an EUA for persons 12 years and older considered immunocompromised or for those unable to receive a COVID-19 vaccine.⁵⁹

By December 2022, however, health officials reported that monoclonal antibodies were no longer considered an effective treatment against the current SARS-CoV-2 strains circulating in the U.S.⁶⁰ The FDA revoked Evusheld’s EUA on January 26, 2023 when it was found to be ineffective against the current circulating strains of COVID-19.⁶¹

Oral Anti-Viral Medications

In December 2021, the FDA authorized the use of two oral anti-viral medications, Paxlovid and molnupiravir, for the treatment of COVID-19 illness.

Paxlovid, manufactured by Pfizer, is recommended for use in children 12 years and older who are positive for SARS-CoV-2 and at high risk for severe disease. The medication is recommended to be given as soon as a diagnosis is made and within five days of symptom onset.

Side effects of the medication include diarrhea, impairment of taste, high blood pressure, and muscle aches. One of the components of Paxlovid, Ritonavir, can cause liver damage. This medication may also lead to HIV-1 drug resistance in persons with undiagnosed or uncontrolled HIV-1. The medication is not recommended for use in persons with kidney or liver disease. According to the FDA, an analysis of the medication in 1,039 individuals reported a 0.86 fatality rate in persons who received Paxlovid, compared to the placebo group (1,046 individuals) that reported a 6 percent death rate. Studies on the medication are ongoing.⁶² Paxlovid has the potential to cause severe or life-threatening reactions if taken with common medications such as antidepressants, anticoagulants, and statins.⁶³

A case study pending peer review posted in April 2022 reported on a 71-year-old male who recovered quickly from COVID-19 illness but experienced an increase in viral loads and symptomatic illness nine days after his initial COVID-19 positive test.⁶⁴ In May 2022, the CDC issued an emergency alert to health care providers regarding the risk of “rebound” COVID-19 infection in individuals treated with Paxlovid. The alert stated that additional treatment with Paxlovid was not recommended and those experiencing a relapse in symptoms should re-isolate for at least five days and wear a mask for at least ten days.⁶⁵ In the summer of 2022, several individuals, including Dr. Anthony Fauci,⁶⁶ President Joe Biden,⁶⁷ and First Lady Jill Biden⁶⁸ reported rebound COVID-19 infection after taking Paxlovid.

In late April 2022, Pfizer announced that Paxlovid did not prevent symptomatic COVID-19 illness in household contacts of persons who took the medication.⁶⁹

Molnupiravir, manufactured by Merck, is authorized for use in adults 18 years and older for the treatment of COVID-19 illness who are positive for SARS-CoV-2 and at risk of severe illness. According to clinical trials, of the 709 individuals who received molnupiravir, 6.8 percent required hospitalization compared to 9.7 percent of the 699 individuals who received the placebo. One person who received molnupiravir died, compared to nine people who received the placebo. This experimental medication is not recommended for use in pregnant women because animal reproductive studies appear to indicate a risk of fetal harm. Reported side effects include diarrhea, nausea, and dizziness.⁷⁰

Molnupiravir is capable of mutating RNA, which has some scientists expressing concerns that the medication could potentially cause new virus variants which may be deadlier.⁷¹

Additional Treatments

High doses of vitamin C given intravenously (IV) have been used to treat COVID-19. Three clinical trials and several smaller studies reported successful outcomes among patients who received IV vitamin C at doses varying from 50 to 200 milligrams per kilogram of body weight to up to 200 mg per kg per day.⁷²

One study published in March 2020 reported:

“High-dose intravenous VC has also been successfully used in the treatment of 50 moderate to severe COVID-19 patients in China. The doses used varied between 10 g and 20 g per day, given over a period of 8–10 h. Additional VC bolus may be required among patients in critical conditions. The oxygenation index was improving in real time and all the patients eventually cured and were discharged.” ⁷³

The Frontline COVID-19 Critical Care Alliance (FLCCC), a group comprised of highly published critical care experts, have outlined a protocol to treat hospitalized COVID-19 patients. In February 2021, the FLCCC’s clinical and scientific rationale on their methylprednisolone, ascorbic acid (vitamin C), thiamine, heparin and co-interventions (MATH+) protocol was peer reviewed and published in Journal of Intensive Care Medicine.⁷⁴ The protocol was reported as effective in the treatment of severe COVID-19 illness requiring hospitalization. Additional treatment co-interventions noted in the research article included the use of melatonin, famotidine, atorvastatin, vitamin D3, and the application of therapeutic plasma exchange (a treatment that replaces an individual’s blood plasma).⁷⁵

The article noted that systematic use of MATH+ in two U.S. hospitals demonstrated an absolute mortality risk reduction of more than 75 percent, or 5.1 percent vs. 22.9 percent, when compared to multiple published COVID-19 hospital mortality rates in the U.S. The article concluded:

“It is exceedingly unlikely that a “magic bullet” will be found, or even a medicine which would be effective at multiple stages of the disease. The Math+ treatment protocol instead offers an inexpensive combination of medicines with a well-known safety profile based on strong physiologic rationale and an increasing clinical evidence base which potentially offers a life-saving approach to the management of COVID-19 patients.” ⁷⁶

Use of Anti-Malaria Medications

In March 2020, two anti-malaria medications, hydroxychloroquine and chloroquine, received EUA authorization to treat COVID-19. The EUA was issued based on laboratory studies that showed these medications to be effective against coronaviruses. Use of these medications, however, quickly became controversial.

On May 22, 2020, The Lancet published a study reporting that hydroxychloroquine was not effective against COVID-19 and was associated with heart arrhythmias and higher death rates. As a result of this study, the World Health Organization (WHO) halted their hydroxychloroquine drug trials. The validity of this study, however, was immediately questioned and when the study data could not be obtained for independent review, The Lancet was forced to retract the study.⁷⁷

Scientists affiliated with the Henry Ford Hospital System in Detroit, Michigan published research on hydroxychloroquine that reported the medication to be effective in reducing the COVID-19 death rate. No heart-related side effects were reported, and outcomes improved when treatment was initiated early.⁷⁸ The study results, however, have been criticized by health officials including Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID).⁷⁹ Hydroxychloroquine administered in combination with zinc and azithromycin has also been reported to be an effective treatment for hospitalized COVID-19 patients.⁸⁰ The FDA, however, revoked the EUA for hydroxychloroquine in mid-June 2020, stating that the medication was ineffective against COVID-19 and potentially harmful.⁸¹

A January 2021 published study in the American Journal of Medicine reported that when the medicine was administered early in the treatment stage, it was effective at halting disease progression, preventing hospitalization, and reducing mortality rates. This study also reported the effectiveness of using the hydroxychloroquine in combination with either azithromycin or doxycycline, two commonly prescribed antibiotics.⁸²

Off-Label Use of Other Drugs

Ivermectin, a medication used to treat parasites, has been found to inhibit SARS-CoV-2, the virus that causes COVID-19, in vitro.⁸³ Australian gastroenterologist Dr. Thomas Borody, known for developing the first peptic ulcer cure, reported that ivermectin administered in conjunction with zinc and the antibiotic doxycycline could be a ‘potential life-saver.’⁸⁴ A January 2021 published study reported that the use of ivermectin was associated with lower rates of death, especially in patients who had severe pulmonary involvement.⁸⁵ A journal study published in April 2021 concluded that:⁸⁶

“Meta-analyses based on 18 randomized controlled treatment trials of ivermectin in COVID-19 have found large, statistically significant reductions in mortality, time to clinical recovery, and time to viral clearance. Furthermore, results from numerous controlled prophylaxis trials report significantly reduced risks of contracting COVID-19 with the regular use of ivermectin. Finally, the many examples of ivermectin distribution campaigns leading to rapid population-wide decreases in morbidity and mortality indicate that an oral agent effective in all phases of COVID-19 has been identified.”

Despite published data to support the use of ivermectin as a treatment for COVID-19, the medication has not been granted approval or authorization by the FDA. On August 26, 2021, the CDC issued a health advisory regarding the use of ivermectin as a treatment option for COVID-19. In the health advisory, the CDC noted that the medication, while FDA-approved for use as a safe treatment option for infections caused by internal and external parasites, was not approved or authorized as a COVID-19 treatment. The CDC warned against use of the medication, and included a warning about the risk of ingesting topical formulation as well as products intended for veterinarian use.⁸⁷

Multiple studies have found ivermectin to be effective in treating COVID-19 illness, preventing hospitalization, and reducing mortality.⁸⁸

The corticosteroid Budesonide, commonly used to treat asthma symptoms, has also been successfully used to treat symptoms of COVID-19. According to a study conducted by the University of Oxford, budesonide significantly decreased urgent care visits and hospitalizations, and when used within seven days of symptom onset, recovery time was decreased. Fever, illness symptoms, including persistent illness symptoms, resolved quicker in study participants who received budesonide.⁸⁹

Additional medications that have shown as effective early treatment options for COVID-19 illness include fluvoxamine, ^{90 91 92} a medication typically used to treat depression, and fenofibrate, a medication used to decrease cholesterol ^{93 94}

Blood plasma donated from individuals who have recovered from COVID-19 was also studied as potential treatment option. In early August 2020, Mayo Clinic researchers reported that this therapy was helpful despite a lack a formal data to support its use.⁹⁵ A study on the use of convalescent plasma to treat moderate COVID-19 illness in adults in India published in the British Medical Journal in October 2020, however, reported that this treatment was not effective in reducing the progression to severe disease or preventing COVID-19 related deaths.⁹⁶

On February 4, 2021, the FDA revised the convalescent plasma EUA to limit it to the use of only high-titer convalescent plasma for early treatment of hospitalized patients or in persons with impaired humoral immunity who are unable to produce an adequate antibody response. Low-titer convalescent plasma was declared ineffective and its use was no longer authorized.⁹⁷

IMPORTANT NOTE: NVIC encourages you to become fully informed about covid-19 and the covid-19 vaccine by reading all sections in the Table of Contents, which contain many links and resources such as the manufacturer product information inserts, and to speak with one or more trusted health care professionals before making a vaccination decision for yourself or your child. This information is for educational purposes only and is not intended as medical advice.

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