Accepted Article

DR ZE ZHANG (Orcid ID : 0000-0002-9544-6683)

Article type : Letter to the Editor

COVID-19 indirect contact transmission through the oral mucosa must not be ignored

Ze Zhang1,2*, Lichao Zhang3, Yanqiao Wang4

1Department of General Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China; 2Department of Hepatobiliary-Pancreatic

Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130000, P.R. China; 3 Department of Parasitology of Zhongshan School of

Medicine, Sun Yat-sen University, Guangzhou, 510080, Guangdong, P.R. China; 4Department of Respiratory Medicine, The Second Hospital of Jilin

University, Changchun, 130041, P.R. China.

Correspondence to:

Dr Ze Zhang, Department of General Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China; phone: +86-18612334484, e-mail:

zzwivehxx@163.com,

Key words: COVID-19; SARS-CoV-2; Oral mucosa

Running Title: ZZ et al: COVID-19 oral mucosa transmission

The authors information and affiliations.

The 1st author: Ze Zhang, Male, Jilin Provence, March 1993, Doctor degree, Department of Hepatobiliary and Pancreatic Surgery, zzwivehxx@163.com

The 2nd author: Lichao Zhang, Female, Guangdong province, Doctor degree, Department of Parasitology of Zhongshan School of Medicine, Sun Yat-sen

University, zhanglc919@163.com

The 3th author: Yanqiao Wang, Department of Respiratory Medicine, The Second Hospital of Jilin University, candyqiao77@jlu.edu.cn

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOP.13019
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 Abstract:
Accepted Article
Background: Coronavirus (CoV) is the single stranded sense RNA virus that has been
known so far with the largest genomic capacity and plenty of natural hosts. In the past
dozens of years, SARS-CoV under the branch of the new evolutionary tree has threatens
greatly global public health and the severe acute respiratory syndrome new coronavirus
(COVID-19) reported in China could cause fatal pathological lesions. Especially in areas
with poor medical care, neglect of indirect transmission can cause more serious
consequences.
Methods: First of all, with reference to SARS-CoV and other relevant studies, the
possibility of virus residues on the surface of multiple media is discussed. Further, it is
found that the surface residue of this substance may be an important factor in iatrogenic
infection.
Results: This correspondence could point out the direction to study the pathomechanism of
COVID-19 infecting human beings.
Conclusions: Mucosa exposure and inappropriate treatment of medical and non-medical
articles used by the patients all could increase the risks of COVID-19 transmission.

Recently, The Lancet has reported the epidemiology, symptoms and treatment
methods of the infected patients of Coronavirus Infected Disease-19 (COVID-19) in
Wuhan, China. 1 As general surgeons, our team thought that the fact that COVID-19 could
transmit through indirect contact of the oral mucosa was ignored.
　　In 44,672 confirmed cases, 1,023 died, with the crude death rate of 2.3%. The report
shows that by February 11, altogether 3,019 medical staff had been affected by COVID-19
(including confirmed cases, suspected cases, clinically diagnosed cases and asymptomatic
carriers, among which there were 1,716 confirmed cases, of which 5 died.) and there was a
possibility that some were affected due to non-occupational exposure. 2 These rescuing and
disease-preventing personnel were under strict professional protection during the fighting
against the epidemic disease by following strictly professional protection opinions issued

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 by China's Center for Disease Control (CCDC); however, newly affected doctors and
Accepted Article
patients are reported continuously, indicating that there could be affection caused by
non-occupational exposure. Later, those who have upper respiratory tract infection as the
initial symptom are confirmed affected by COVID-19, which highlights that besides
spreading through the respiratory tract by inhaling directly droplets and possible aerosols,
COVID-19 could also spread through direct or indirect contact with the oral, the nasal
cavity and the eye mucous membranes. At present, most of the medical workers are
focused on the routes of respiratory infection of COVID-19, and suggested by Lu et al,
they also begin to pay attention to the transmission through the eye mucous membranes;
however, the possibility that the virus could invade the organs through oral mucosa by
touching indirectly the patients' secretions, excrements and other polluted articles might be
ignored.
More and more evidences have shown that COVID-19 has highly similar biological
properties with severe acute respiratory syndrome corona virus (SARS-CoV). Previous
studies have revealed that SARS-CoV could be detected from three major excrements
(sputum, feces and urine) and blood of the patients 3 . At 24℃, SARS-CoV could survive
about 5 days in sputum and faces, 10 days in urine and 15 days in blood. At room
temperature, it could survive about 3 days on the surface of filter paper, gauze, plastics and
glass 4 . SARS-CoV could be transmitted indirectly by invading some patients through oral
mucosa contact with polluted water source and food 5 . Mucosa exposure and inappropriate
treatment of medical and non-medical articles used by the patients all could increase the
risks of SARS-CoV transmission. This suggests that acute respiratory infection might be
caused by mucosa contact with articles polluted by COVID-19 during non-occupational
time.
This article is of far-reaching significance. First, it could remind people on the firing
line and the mass of the transmission pathway of COVID-19. It should also be noted that
indirect contact of oral mucosa is not exactly the same as oral-faecal route of transmission.
Further, it is suggested by this article that medical and non-medical articles as well as

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 personal belongings used by the patients infected by COVID-19 should be disposed
Accepted Article
appropriately, which could help lower the risks of medical workers being infected.

References:
1. Huang C, Wang YM, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus

in Wuhan, China. Lancet 2020; published online Jan 24. https://doi.

org/10.1016/S0140-6736(20)30183-5.

2. China's Center for Disease Control (CCDC) reported that more than 3,000 medical workers were

infected with the new coronavirus, with 1,716 confirmed cases. Jan 17, 2020.

http://www.chinanews.com/gn/2020/02-17/9094798.shtml.

3. He Z, Zhuang H, Zhao C, Dong Q, Peng G, Dwyer DE. Using patient-collected clinical samples and sera to

detect and quantify the severe acute respiratory syndrome coronavirus (SARS-CoV). VIROL J. 2007

2007-03-27;4:32.

4. Otter JA, Donskey C, Yezli S, Douthwaite S, Goldenberg SD, Weber DJ. Transmission of SARS and MERS

coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination. J

HOSP INFECT 2016; 92(3): 235-50.

5. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The severe acute respiratory syndrome. N Engl J Med

2003; 349: 2431–41.

Statement: We declare no competing interests.

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