Effect of Natural Food on Gut Microbiome and Phospholipid Spectrum of Immune Cells in COVID-19 Patients
Phase: NA
Conditions: COVID-19
Sponsor: Asfendiyarov Kazakh National Medical University

1 
Study protocol 
 
Official Title: Effect of Natural Food on Gut Microbiome and Phospholipid Spectrum 
of Immune Cells in COVID-19 Patients 
NCT number: NCT05970861 
Document date: The 1st of October, 2024 
  
  
Main Investigator: Abdugani Musayev, Ph.D., M.D. 
Central Contact Backup (Project Manager): Vildan Indershiyev 
Study Officials:   
Ainur Yeshmanova, Ph.D.  
Nikolay Safonov 
Zhannat Nurmakhanova, Ph.D 
Zhanar Nurgaliyeva, Ph.D. 
 
Keywords: COVID-19, gut microbiome, antiphospholipid antibodies, rehabilitation, 
food products 
 
 

2 
Study Description 
Brief Summary:  
The efficacy of natural foods such as freeze-dried mare's milk (Saumal) in post-COVID 
syndrome therapy has not been studied. The literature review has shown that 
researchers have focused more on evidence-based medications and less on natural 
products. Some raw foods, such as freeze-dried mare's milk, contribute to forming 
complete immune complexes and have antioxidant, membrane stabilizing, and antiviral 
effects. 
The use of Saumal proved its effectiveness in patients suffering from chronic hepatitis 
C. After 4 weeks of using freeze-dried mare's milk, the biodiversity of the intestinal 
microbiome was increased. The content of bacteria secreting short-chain fatty acids 
also increased. 
The study aims to confirm these effects at the gene level in patients who underwent 
COVID-19. This study will allow us to develop a highly evidence-based component of 
rehabilitation therapy in patients after COVID-19. 
Detailed Description: 
The study consists of three stages.  
Stage I. Randomized division of 75 patients under study into a main group of 38 
patients receiving Saumal for 4 weeks and a control group of 37 patients not receiving 
Saumal. All respondents have suffered from COVID-19 in the last 6 months. At the 
moment of the research, all patients will be staying in rehabilitation centers in Almaty 
City. 
The study's biological material will be collected from the respondents (gut microbiome, 
antiphospholipid antibodies, biochemical blood analysis (glucose, ALT, AST, uric 
acid, TAGs, alkaline phosphatase)). 
Stage II. The main group will be given Saumal for four weeks, after which the gut 
microbiome, antiphospholipid antibodies, and biochemical blood analysis will be 
collected from both groups again. This will allow us to assess the impact of freeze-
dried mare's milk on the condition of the gut microbiome, antiphospholipid antibodies, 
and biochemical blood analysis. 
Stage III. Data analysis. 
1. Based on the results of gut microbiome sequencing, ELISA (antiphospholipid 
antibodies), and biochemical blood analysis in the main and control groups, we 
determine the dynamic changes of those parameters during COVID-19 
rehabilitation. 
2. According to the results, the effectiveness of Saumal itself regarding these 2 
parameters will be evaluated. 
3. Develop recommendations and an algorithm for patient management after 
COVID-19 to prevent complications. 
 

3 
Study Design 
Study Type: Interventional  
Primary Purpose: Treatment 
Interventional Study Model: 
Parallel Assignment 
Number of Arms: 2 
Masking: 
None (Open Label) 
Allocation: Randomized 
Enrollment: 60 patients. Originally, we planned to include 38 patients in the main 
group and 37 in the control group. Overall, these groups were evenly divided, with 30 
patients in each group. 
 
Arms and Interventions 
 
Arms 
Assigned Interventions 
Experimental: Main Group 
Patients who had suffered from COVID-19 in 
the six months before the start of the study. 
Patients will receive Saumal (freeze-dried mare 
milk) for four weeks. 
Dietary Supplement: Freeze-dried Mare Milk 
(Saumal) 
Freeze-dried Mare Milk (Saumal) is frequently 
reported for having therapeutic and dietary 
properties associated with specific chemical 
composition and certain physical properties of 
the product. It contains a total of about 40 
biologically active components, the most 
important of them vitamins A, C, B1, B2, B6, 
and B12, amino acids, enzymes, and trace 
elements (low molecular weight peptides, 
lactalbumins, and globulins). Saumal will be 
administered to patients at a dose of 25 grams of 
dry powder per 200 ml of water, 2 times a day, 
30 minutes before the meal, for 4 weeks. 
No Intervention: Control Group 
Patients who had suffered from COVID-19 in 
the six months before the start of the study. 
There will be no intervention. 
 
 
Eligibility 
 
Minimum Age: 18 Years   
Maximum Age: 75 Years   
Sex: All   
Gender Based: No   
Accepts Healthy Volunteers: No   
 
Inclusion Criteria: 
Age 18 years and older; 
Patients in rehabilitation after COVID-19; 
Signed informed consent; 

4 
Presence of patient's history of COVID-19, reliably established by PCR+ /presence of 
IgG/ diagnosis of coronavirus pneumonia on Computer Tomography based on 
discharge from hospital or outpatient records. 
 
Exclusion Criteria: 
Chronic inflammatory bowel disease; 
Gut microbiota transplantation; 
Chronic pancreatic disease, period of exacerbation; 
Liver cirrhosis, Metavir stage 3-4; 
Any disease in the decompensation stage; 
Neuralgic and psychological disorders that interfere with the study; 
Cancer; 
Non-transportable patients; 
Patients who do not reside in Almaty; 
Patients who have refused to participate in the study. 
 
Examined for eligibility - 76 people;  
Confirmed eligible - 60 people. According to our strict exclusion criteria, we had to 
remove 16 people [8 – oncological patients, 5 – moved house, 3 patients refused to 
participate]; 
Included in the study - 60 patients;  
Completing follow-up and analysed - 60 patients. 
 
Statistical Analysis Plan 
Gut microbiota: 
IBM SPSS ver. 23.0 (Chicago, IL, USA) was used to determine the statistical 
significance of the obtained data. All the indicators were verified for compliance with 
the law on normal distribution. If the variables obeyed this law, the Student's paired t-
test was applied to determine statistical significance between the values before and 
after milk intake. Otherwise, the Wilcoxon sign rank criterion was used. 
A single-factor analysis of variance was employed to verify the effect of 
administering freeze-dried mare's milk, which could potentially affect the indicators of 
gut microbiota. 
Antiphospolipid antibodies: 
The 95% confidence interval for aPL value was calculated for both median and 
mean. The confidence interval for the latter one was calculated in the descriptive 
statistics menu in IBM SPSS ver. 23.0 (Chicago, IL, USA). 
It is necessary to find the value of the confidence coefficient (Student's criterion 
(t)) in the table of critical t-values, considering the total number of respondents (n) to 
find out a confidence interval for the median with a given confidence probability (p). 
After that, the calculation of the natural integer number (C) is needed for such a 
probability value: Cp = (n/2 - t(p) √n /2). The lower confidence limit for the median is 
X (Cp), where X is the ordinal number of the value in the ranked variation series 
corresponding to the lower boundary of the confidence interval. The upper confidence 
limit for the median is X (n + 1 - Cp), where X is the ordinal number of the value in 

5 
the ranked variation series corresponding to the upper boundary of the confidence 
interval. 
If the normal distribution law is followed, the Student's paired t-test was used to 
determine statistical significance between values before and after freeze-dried mare's 
milk. If not, the Wilcoxon sign rank criterion was used for intergroup comparison. One-
way analysis of variance (ANOVA) was used to determine the relationship between 
the mare's milk prescription factor and aPL levels in both groups. 
Quality of life: 
IBM SPSS ver. 23.0 (Chicago, IL, USA) was used to determine the statistical 
significance of the obtained data. All the indicators were verified for compliance with 
the law on normal distribution. If the variables obeyed this law, the Student's paired t-
test was applied to determine statistical significance between the values before and 
after milk intake. Otherwise, the Wilcoxon sign rank criterion was used. 
A single-factor analysis of variance was employed to verify the effect of 
administering freeze-dried mare's milk, which could potentially affect the quality-of-
life scores. 
Results section 
 
Gut microbiota analysis. 
In the main group, after taking freeze-dried mare's milk, there was a decrease in 
the content of bacteria phyla Bacteroidetes, Proteobacteria, Verrucomicrobia and 
Chloroflexi (by 3.03%, 2.83%, 0.47% and 0.16, respectively), and an increase in the 
content of bacteria phyla Nitrospirae, Tenericutes, Cyanobacteria, Spirochaetes, 
Euryarchaeota, Actinobacteria and Firmicutes (by 0.02 %, 0.05%, 0,15%, 0,17%, 
0,24%, 1,42% and 7.62%, respectively). 
The Fusobacteria phylum was absent according to the results of mare's milk 
intake in all respondents. The Elusimicrobia phylum, on the contrary, was present in 
some respondents as a result of therapy. 
Attention is also drawn to the presence of the Synergistetes phylum, which was 
absent in the control group both before and after therapy. Moreover, the difference 
between the Firmicutes, Proteobacteria, Chloroflexi, Cyanobacteria and Synergistetes 
phyla was statistically significant (Table 1). 
Table 1. The percentage terms of all phyla of the gut microbiota in the main group before and after taking 
freeze-dried mare's milk (CI - confidence interval). 
Phylum name 
Before 
After 
95% CI (t-student) 
p (t-student) 
Bacteroidetes 
32,32% 
29,43% 
-0,01; 0,07 
0,178 
Firmicutes 
45,31% 
51,87% 
-0,09; -0,02 
0,001 
Proteobacteria 
9,25% 
6,52% 
0,1; 0,28 
<0,001 
Actinobacteria 
3,75% 
4,9% 
-0,15; 0,14 
0,951 
Euryaychaeota 
1,28% 
1,52% 
-0,42; 0,1 
0,204 
Verrucomicrobia 
1,29% 
0,83% 
-0,09; 0,32 
0,223 
Chloroflexi 
0,23% 
0,07% 
0,04; 0,28 
0,011 
Cyanobacteria 
0,16% 
0,31% 
-1,95; -0,17 
0,028 
Spirochaetes 
0,08% 
0,25% 
-0,51; 0,17 
0,324 
Nitrospirae 
0,01% 
0,03% 
-0,07; 0,02 
0,235 
Tenericutes 
0,04% 
0,09% 
-0,2; 0,01 
0,491 
Fusobacteria 
0,07% 
0,00% 
-0,05; 0,2 
0,247 
Elusimicrobia 
0,00% 
0,11% 
-0,24; 0,02 
0,109 

6 
Synergistetes 
0,01% 
0,09% 
-0,14; -0,02 
0,009 
 
In the control group, after taking freeze-dried mare's milk, there was a decrease 
in the content of bacteria phyla Bacteroidetes, Firmicutes, Chloroflexi and 
Cyanobacteria (by 2.5%, 0.4%, 0.07% and 0.07%, respectively), and an increase in the 
content of bacteria phyla Spirochaetes, Tenericutes, Fusobacteria, Verrucomicrobia, 
Proteobacteria, Euryarchaeota and Actinobacteria (by 0.005%, 0.01%, 0,04%, 0,24%, 
0,26%, 0,48% and 3.56%, respectively). 
 
The Nitrospirae and Elusimicrobia phyla were absent as a result of taking mare's 
milk in all respondents of the control group. At the beginning of therapy, some 
respondents were found to have bacteria of the Caldithrix phylum, which were absent 
during the repeated measurement. The Thermotogae phylum was found in several 
members of the control group during two measurements. 
 
Moreover, the difference between the Actinobacteria and Chloroflexi phyla in 
the control group was statistically significant (Table 2). 
 
Table 2. The percentage terms of all phyla of the gut microbiota in the control group after 2 stool tests (CI - 
confidence interval). 
Phylum name 
First test 
Second test 
95% CI (t-student) 
p (t-student) 
Bacteroidetes 
32,27% 
29,77% 
-0,06; 0,08 
0,754 
Firmicutes 
46,5% 
46,1% 
-0,06; 0,07 
0,899 
Proteobacteria 
7,65% 
7,91% 
-0,1; 0,12 
0,823 
Actinobacteria 
5,8% 
9,36% 
-0,46; -0,1 
0,003 
Euryaychaeota 
0,39% 
0,87% 
-0,74; 0,24 
0,209 
Verrucomicrobia 
1,72% 
1,96% 
-0,97; 0,85 
0,871 
Chloroflexi 
0,10% 
0,03% 
0,002; 0,15 
0,044 
Cyanobacteria 
0,41% 
0,34% 
-1,42; 1,89 
0,728 
Spirochaetes 
0,007% 
0,012% 
-0,01; 0,004 
0,324 
Nitrospirae 
0,01% 
0,00% 
-0,01; 0,02 
0,324 
Tenericutes 
0,04% 
0,05% 
-0,12; 0,1 
0,857 
Fusobacteria 
0,01% 
0,05% 
-0,13; 0,05 
0,357 
Elusimicrobia 
0,03% 
0,00% 
-0,01; 0,07 
0,090 
Caldithrix 
0,02% 
0,00% 
-0,01; 0,03 
0,160 
Thermotogae 
0,02% 
0,01% 
-0,03; 0,06 
0,454 
 
The proportion of Bacteroidetes and Firmicutes in the gut microbiota is most 
significant. Summarizing their values in the main and control groups, we can see that 
their content increased in the former and decreased in the latter. Statistical analysis 
revealed a significant difference in the content of these phyla between the main group 
compared to the control group (Table 3). 
 
Table 3. The percentage terms of Bacteroidetes and Firmicutes phylum in the main and control groups. 
Main group 
Control group 
Bacteroidete
s+Firmicutes 
(before) 
Bacteroidetes
+Firmicutes 
(after) 
p (Wilcoxon) 
Bacteroidete
s+Firmicutes 
(first test) 
Bacteroidetes
+Firmicutes 
(second test) 
p (Wilcoxon) 
77,63% 
81,3% 
0,026 
78,76% 
75,87% 
0,213 

7 
 
To determine the effect of freeze-dried mare's milk on the gut microbiota at the 
phylum level, a one-factor analysis of variance was performed. A statistically 
significant relationship between such a factor as the administration of freeze-dried 
mare's milk was revealed in the Firmicutes, Elusimicrobia and Proteobacteria phyla 
(Table 4). 
 
Table 4. The relationship between the use of prescribed freeze-dried mare's milk and indicators of 
gut microbiota at the phylum level. 
Phylum name 
p (One-way ANOVA) 
Bacteroidetes 
0,180 
Firmicutes 
0,048 
Proteobacteria 
0,043 
Actinobacteria 
0,186 
Euryaychaeota 
0,403 
Verrucomicrobia 
0,583 
Chloroflexi 
0,220 
Cyanobacteria 
0,280 
Spirochaetes 
0,340 
Nitrospirae 
0,143 
Tenericutes 
0,657 
Fusobacteria 
0,140 
Elusimicrobia 
0,044 
Bacteroidetes + Firmicutes 
0,037 
 
Overall, the intake of freeze-dried mare's milk by post-COVID patients 
primarily contributed to an increase in the content of the sum of two major phyla of 
gut microbiota — Bacteroides and Firmicutes, with the latter being particularly 
significant. There is also a notable decrease in the number of bacteria from the 
Proteobacteria phylum in the main group, which includes representatives of pathogenic 
microflora. 
 
Antiphospholipid antibody analysis. 
 
29 out of 30 main group patients (96.67%) had normal IgM and IgG levels before 
taking freeze-dried mare's milk. In the case of the control group, aPL levels were 
normal in all respondents. The aPL levels were normal in patients of both groups after 
the second ELISA (Table 5).  
 
Table 5. Antiphospholipid antibody scores of each patient in the main and control groups after two assays 
(aPL -antiphospholipid antibodies). 
Main group 
Control group 
aPL (before) 
aPL (after) 
aPL (first assay) 
aPL (second assay) 
IgM 
(U/ml) 
IgG (U/ml) 
IgM (U/ml) 
IgG (U/ml) 
IgM 
(U/ml) 
IgG 
(U/ml) 
IgM 
(U/ml) 
IgG (U/ml) 
8,97 
1,55 
6,22 
1,34 
1,33 
1,2 
1,91 
1,8 
2,7 
0,943 
2,45 
1,1 
4,3 
4,1 
4,11 
3,87 
0,936 
0,535 
0,936 
0,535 
1,32 
1,46 
1,3 
1,35 
1,12 
0,841 
1,12 
0,841 
4,5 
4,3 
3,2 
2,1 
3,17 
0,943 
2,61 
1,01 
5,1 
4,5 
3,33 
3,51 
3,56 
0,433 
3,21 
0,877 
5,89 
5,67 
5,64 
6,01 

8 
27,2 
1,45 
3,98 
1,2 
3,1 
2,89 
2,67 
2,1 
7,77 
2,25 
4,01 
2,34 
5,22 
6,01 
3,77 
4,13 
1,46 
5,47 
0,56 
0,98 
8,97 
9,34 
6,54 
7,8 
1,53 
22,4 
4,01 
2,67 
6,32 
6,54 
4,78 
5,33 
1,43 
1,1 
3,1 
2,56 
6,89 
7,2 
5,89 
6,6 
3,46 
1,21 
3,5 
1,11 
6,4 
5,6 
6,1 
5,1 
4,42 
1 
4,21 
1,12 
5,12 
4 
4,85 
3,66 
4,42 
1 
4,21 
0,66 
8,9 
9,8 
7,91 
8,76 
1,35 
1,22 
1,33 
1,56 
0,654 
0,533 
0,632 
0,612 
2,96 
2,06 
2,9 
2 
3,57 
3 
3,4 
2,76 
2,26 
1,55 
2,12 
1,41 
2,67 
2,45 
2,3 
1,98 
3,14 
1,67 
3,14 
1,67 
8,43 
8,12 
7,3 
7,6 
0,78 
3,25 
0,98 
2,65 
9,52 
9,9 
9,21 
9,43 
4,37 
1,58 
4,01 
1,76 
5,99 
5,76 
5,77 
5,4 
1,27 
1,88 
1,34 
1,7 
5,99 
5,76 
5,54 
5,32 
1,48 
1,67 
1,44 
1,66 
4,06 
4 
3,8 
3,4 
1,27 
0,82 
0,93 
0,7 
5,6 
6,7 
5,8 
6,5 
3,69 
1,85 
3,41 
2,1 
5,78 
6,3 
5,65 
6,2 
0,88 
1,06 
1,32 
1,01 
6,8 
7,4 
6,32 
6,54 
5,2 
1,15 
4,34 
1,45 
4,89 
5,1 
4,76 
4,7 
8,5 
1,58 
7,21 
1,33 
7,2 
7,8 
6,5 
7,1 
1,48 
0,85 
1,56 
1,01 
0,64 
0,77 
0,77 
0,87 
2,67 
1,18 
0,78 
0,98 
2,31 
2,1 
2,22 
1,98 
0,98 
1,61 
1,12 
1,45 
1,2 
2,3 
1,5 
2,6 
 
There were no significant differences between the aPL values of the main and 
control groups (Table 6). 
 
Table 6. Statistical analysis of antiphospholipid antibody levels of patients in the main and control 
groups after two assays (CI - confidence interval). 
 
95% CI (first assay) 
95% CI (second assay) 
Main group, IgM, mean 
1,97; 5,66 
2,12; 3,36 
Main group, IgG, mean 
0,73; 3,67 
1,20; 1,65 
Control group, IgM, mean 
4,02; 5,89 
3,63; 5,26 
Control group, IgG, mean 
4,03; 6,01 
3,60; 5,41 
Main group, IgM, median 
1,43; 3,69 
1,33; 3,98 
Main group, IgG, median 
1; 1,67 
1,01; 1,67 
Control group, IgM, median 3,57; 6,32 
3,2; 5,8 
Control group, IgG, median 
3; 6,54 
2,6; 6,2 
 
The next calculations were done to stock parameters, before bringing them to a 
normal distribution. A statistically significant difference was found between IgM 
values before and after taking freeze-dried mare's milk. There was the statistically 
significant difference in both IgM and IgG values in the control group (Table 7). 
 
Table 7. Statistical analysis of stock antiphospholipid antibody levels. 
Main group 
Control group 
 
IgM 
IgG 
 
IgM 
IgG 
p-value (Wilcoxon) 
0,021 
0,471 
p-value (Wilcoxon) 
0,0001 
0,0001 
 
 
After bringing the variables to the normal distribution, the statistical 
significance was found in the control group only (Table 8). 
 
 

9 
Table 8. Statistical analysis of normally distributed antiphospholipid antibody levels. 
 
95% CI 
p-value (t-student) 
Main group, IgM 
-0,03; 0,11 
0,185 
Main group, IgG 
-0,07; 0,11 
0,726 
Control group, IgM 
0,04; 0,14 
0,001 
Control group, IgG 
0,05; 0,15 
0,0001 
 
 
ANOVA was performed to determine the direct effect of the natural food 
product on the aPL values (Table 9). ANOVA did not reveal any statistical 
significances. 
 
Table 9. Finding the effect of the freeze-dried mare's milk on the antiphospholipid antibody values 
(ANOVA - analysis of variance). 
Antibody name 
p (One-way ANOVA) 
IgM 
0,541 
IgG 
0,938 
 
aPL values in almost all patients of both groups were ranged normally. The intersection 
of all confidence intervals of medians and means indicates the absence of statistical 
significance between these indicators. The results before and after bringing the aPL 
values to normal distribution differ greatly, especially for the IgM level in the main 
group. One-factor analysis of variance also showed the lack of significance of the 
studied factor. These several theses can explain the given results. First, initial aPL 
values could have been normalized over 6-9 months after COVID-19. Second, there 
were screening kits in the study. Therefore, the obtained results do not show the levels 
of specific phospholipids (phosphatidylcholine, phosphatidylethanolamine, aCL, anti-
β2-GP1, etc.). Third, the severity of COVID-19 was not considered as an inclusion 
criterion. 
 
Quality of life analysis. 
 
The quality of life of post-COVID patients in the main group statistically 
significantly improved in both physical and mental health components after using 
mare's milk. In the control group, there was no statistically significant change in 
quality-of-life indicators for both physical and mental health components. Even though 
the average score for the physical component in the control group is higher than in the 
main group, the level of statistical significance and the confidence interval of both 
groups allow us to conclude that freeze-dried mare's milk can have a positive effect on 
this indicator of the quality of life of post-COVID patients (Table 10). 
 
Table 10. The average quality-of-life score in patients of the main and control groups. 
 
Quality-of-life components 
Physical 
Mental 
Before 
After 
95% 
CI 
(t-
student) 
p 
(t-
student) 
Before 
After 
95% CI 
(t-
student) 
p 
(t-
student) 
Main group 
43,515 
47,965 
-7,34;  
-1,56 
0,004 
45,06 
49,524 
-7,02;  
-1,91 
0,001 

10 
Control 
group  
50,451 
50,797 
-0,14; 
0,09 
0,647 
47,46 
49,393 
-0,33; 
0,03 
0,091 
 
The impact of directly administering a natural food product on the quality of life 
of post-COVID patients was verified using a one-way analysis of variance. The 
analysis showed that the relationship between mare's milk and quality of life indicators 
for the physical component is statistically significant. However, no statistical 
significance was observed for the mental component (Table 11). 
 
Table 11. The relationship between the prescribed freeze-dried mare's milk and the quality-of-life scores. 
Quality-of-life components 
p (One-way ANOVA) 
Physical 
0,014 
Mental 
0,146 
 
References 
1. Zuo T, Zhang F, Lui GCY, et al. Alterations in gut microbiota of patients with 
COVID-19 during time of hospitalization. Gastroenterology. 2020;159:944–55. 
2. Yeoh YK, Zuo T, Lui GC, et al. Gut microbiota composition reflects disease 
severity and dysfunctional immune responses in patients with COVID-19. Gut. 
2021;70(4):698-706. doi:10.1136/gutjnl-2020-323020 
3. Romaniuk K., Majszyk-Świątek M., Kryszak K., Danielewicz A., Andraszek K. 
Alternative use of mare milk. Folia Pomer. Univ. Technol. Stetin. 
2019;348:121–130. doi: 10.21005/AAPZ2019.49.1.13. 
4. Fantuz F., Salimei E., Papademas P. Macro- and micronutrients in non-cow 
milk and products and their impact on human health. In: Tsakalidou E., 
Papadimitriou K., editors. Non-Bovine Milk and Milk Products. 1st ed. 
Elsevier Academic Press; London, UK: 2016. pp. 209–261. 
5. Kushugulova A., Kozhakhmetov S., Sattybayeva R., Nurgozhina A., Ziyat A., 
Yadav H., Marotta F. Mare’s milk as a prospective functional product. Funct. 
Food Health Dis. 2018;8:537–543. doi: 10.31989/ffhd.v8i11.528.  
6. Musayev, A., Yeshmanova, A., Pakhomenko, Y., Kozhakhmetov, S.S., 
Kushugulova, A.K. Effects of Environmental Pollutants on Intestinal 
Microbiome Under the Influence Of Mare's Milk In Patients with Hepatitis C. 
Procedia 
Environmental 
Science, 
Engineering 
and 
Management 
2020;7(4):605–611.