key: cord-0077157-2asrianb
authors: Qiu, Jian-Nan; Deng, Hong-Yong
title: Taking Proactive Action: Introduction to the Prevention and Treatment of COVID-19 with Traditional Chinese Medicine
date: 2021-03-31
journal: nan
DOI: 10.4103/cmac.cmac_4_21
sha: 05ce7c5d7c2c95da3e71efc2525915164ae9723c
doc_id: 77157
cord_uid: 2asrianb

Since the outbreak of coronavirus disease-2019 (COVID-19), traditional Chinese medicine (TCM) has fully displayed its strength and specialty and has played an important role in the prevention and treatment of the pandemic. Faced with the unexpected development of the pandemic, the Chinese government has responded quickly and attached great importance to the effect of TCM. Comprehensive therapy integrating Chinese and Western medicine has achieved remarkable success. To summarize and introduce the prevention and treatment of COVID-19 with TCM, this article covers the perspectives of policy guideline issue, clinical diagnosis participation, and scientific research progress.

The outbreak and rapid spread of coronavirus disease-2019 (hereinafter referred to as COVID-19) has become a global public health emergency which threatens the human life and health seriously. A cumulative of 38,789,204 confirmed cases including 1,095,097 deaths had been reported globally by October 17 Beijing time. [1] Meanwhile, the epidemic situation in China was soon brought under control with reported sporadic cases. With its outstanding advantages, traditional Chinese medicine (TCM) has played a crucial role in this battle against the COVID-19 and has mutually reinforced its effect together with Western medicine. According to the white paper Fighting COVID-19 China in Action released by the State Council Information Office of the People's Republic of China, up to 92% confirmed cases were co-treated with TCM. For confirmed patients in Hubei province, both usage rate and total response rate exceeded 90%. [2] Due to insufficient evidence of antiviral and antibiotic therapies at the early stage of COVID-19 pandemic, there are not yet effective drugs against this novel coronavirus. [3] As the treasure of Chinese civilization, TCM guided by the concept of holism and syndrome differentiation has combined with Western medicine and mutually complemented each other's advantages in the clinical diagnosis and treatment of COVID-19 patients, and its multiple targeting therapy has achieved good results. Looking back at the current progress in China, the epidemic would have never been subdued without the supplement and promotion of TCM from the government, medical staff, and science researchers. To provide further reference, this article summarize the relevant integrative clinical experience from the perspectives of policy guideline issue, clinical diagnosis participation, and scientific research progress.

on the prevention and control of COVID-19 was held in Beijing. Sun Chunlan (孙春兰), the Vice Premier of the State Council, attended the conference. She emphasized the importance of lawful, scientific, and orderly prevention, as well as the resolution of curtailing the spread of virus. [4] On January 25, the Spring Festival, President Xi Jinping chaired the meeting on epidemic prevention and control. A working group for epidemic response was formed to promote and strengthen the first line local prevention and control defense. [5] In accordance with the unified deployment, the National Administration of Traditional Chinese Medicine (NATCM) has introduced a series of anti-epidemic policies with TCM. To deepen the implementation of integrative Chinese medicine and Western medicine treatment, on January 27, NATCM issued a Notice on this topic from the following five aspects: building joint treatment mechanism; improving medical care capacity of medical staff; carrying out standard medical care; focusing on the combination of clinical and scientific research, and sharing case information. [6] In order to further implement the overall plan of anti-epidemic effort, give full play to the supporting role of informatization and propel the deep engagement of TCM, on February 8, NATCM issued the Notice on Strengthening Information Support for the Prevention and Treatment of COVID-19 with TCM. The Notice summarized typical practice for the purpose of strengthening information support by carrying out the following five tasks; Internet-based diagnosis and treatment service provided by TCM medical organization, Internet-based TCM prevention and control at grass root level; online TCM advisory services; "Internet+" government affairs service; and basic guarantee. [7] As the epidemic has become constant, China will be in a situation of ongoing prevention and control. To fully implement the overall control strategy of "preventing both foreign input and domestic rebound," on May 15, the office of NATCM released the Notice on Implementing TCM Works under Normalized Prevention and Control. In the notice, it is demanded that policies should be implemented accurately at different areas. Both TCM medical staff and materials should be in full supply.

Rehabilitation therapy with TCM characteristics should be in widespread use, and TCM health education and scientific protection should be advocated. [8] Release traditional Chinese medicine coordination scheme The Chinese National Health Commission has released the eight versions of COVID-19 diagnosis and treatment schemes successively from January to August 2020. Each version, especially the third version, included TCM prevention and control. On the basis of syndrome differentiation of the second edition, the third edition further confirmed the pathogenesis characteristics of COVID-19 as "dampness, heat, toxin and stasis," and added specific treatment scheme. [9] The fourth edition of the schemes divided the TCM treatment of COVID-19 into the medical observation phase and clinical treatment phase. The latter can be further divided into four stages, namely the initial stage, the intermediate stage, the severe stage, and the recovery stage, which correspond respectively to four syndrome types of TCM: Stagnation of cold-dampness in the lung, epidemic toxin blocking the lung, internal blockage and external collapse, and qi deficiency of the lung and spleen. Chinese patented medicine for the medical observation phase, intermediate stage, and severe stage was also recommended. [10] Through differentiating syndrome, the cause of this pandemic is identified as dampness toxin, and its principal pathogenesis are "dampness, heat, toxin, and stasis". Considering the clinical manifestations of mild type, common type, severe type, and critical type, it was initially considered that COVID-19 had distinct stage-related progression and favorable or unfavorable prognosis. Therefore, the treatment based on syndrome differentiation by stage was suggested:

The initial stage (mild type and common type), the progressive stage (severe type), the critical stage (critical type), and the recovery stage. In the initial stage, the location of disease was neither exterior nor interior. Instead, it was dampness toxin was stagnated at the membrane source of upper energizer. In the progressive stage, dampness toxin transformed into heat, and then the dampness immersed the lung, obstructed the lung and even blocked the lung, thus causing internal blockage and external collapse. For the severe type, patients should be treated from qi level and ying level, while for the critical type, there were deteriorated cases, so individual differentiation was required. As the epidemic aggravated, the herbal prescriptions also kept adjusting. Compared with the fifth edition, the differentiation of syndrome types for the herbal medicine treatment in the sixth and seventh editions was more precise, and the composition of prescriptions and dosages were more complicated. In the sixth edition, the clinical treatment phase was segmented into mile type, common type, severe type, critical type, and the recovery stage. A general prescription called "Qing Fei Pai Du Decoction" was recommended for the clinical treatment phase based on the summarization and analysis of empirical formulas and effective prescriptions across China. [11] Moreover, the application of TCM injection was valued in the treatment of severe and critical patients in the seventh edition. As the Head of Beijing Hospital of Traditional Chinese Medicine, Liu Qingquan was also the deputy chief of National Expert Group on TCM Treatment. [12] He pointed out that, "COVID-19 is an emerging disease for us, so the seventh edition provides us with more scientific guidance on the application of Chinese patented medicine and TCM injection." For the severe and critical patients with mechanical ventilation, if they suffered from abdominal distension, inhibited defecation or constipation, 5-10 g of raw Da Huang (大黄 Radix et Rhizoma Rhei) could be used for treatment. For patient-ventilator asynchrony, 5-10 g of raw Da Huang (大黄 Radix et Rhizoma Rhei) and 5-10 g Mang Xiao (芒硝 Natrii Sulfas) could be used after giving depressant and muscle relaxant. On August 18, the General Office of National Health Commission and the Office of NATCM issued COVID-19 Diagnosis and Treatment Schemes (Trial Eighth Version). [13] By summarizing clinical experiences, Chinese medical staff have continually kept optimizing therapeutic measures by amending and perfecting the schemes, thus, providing comprehensive guidelines and specifications for improving COVID-19 diagnosis and treatment.

Traditional Chinese medicine participates in the clinical diagnosis and treatment Looking back at its history, TCM has played an important role in fighting against infectious diseases, including small pox, plague, SARS, influenza A, and avian influenza. [14] In the early outbreak of COVID-19, various provinces and cities actively responded to the call of the central government. Integrated Chinese medicine and Western medicine therapy and syndrome differentiation were applied in an individualized way to help patients detach from ventilator and Extracorporeal Membrane Oxygenation. These measures reduced bacterial cross-infection and improved rescue rate. According to the information published by NATCM, summarization of data about TCM diagnosis and treatment from some provinces and cities at the early outbreak of COVID-19 are presented in Table 1 . The rates of applying integrated Chinese medicine and Western medicine were close among provinces and cities, whereas effective rate and cure rate of TCM-involved treatment varied greatly. Different provinces and cities had different evaluation criteria on therapeutic efficacy and they conducted different independent treatments but what causes such variations remains to be further explored.

Frequently-used traditional Chinese medicine prescriptions, Chinese patent medicine, and other therapies On January 6, 2020, the General Office of National Health Commission and the Office of NATCM issued Notice on Recommending "Qing Fei Pai Du Decoction" in the Treatment of COVID-19 with Integrated Chinese Medicine and Western Medicine Approach, thus providing guidance for the clinical application of this prescription. [15] "Qing Fei Pai Du Decoction" was first applied in the emergency clinical observation of 214 confirmed cases in the provinces of Shanxi, Hebei, Shaanxi, and Heilongjiang, with an effective rate over 90%. [16] Furthermore, as the most-used prescription in Wuhan city, Hubei province, a total of 390,000 bags of decoction and half a million doses of compound "Qing Fei Pai Du Decoction" granule were distributed to designated hospitals and isolation centers. The extensive use of this prescription acquired good curative effect and received no obvious specific adverse drug reaction reporting. [17] Various clinical observations and fundamental researches have proven that "Qing Fei Pai Du Decoction" is quick-acting, efficient, safe, and cost-effective. [18] [19] [20] [21] According to the 8 th edition of the Scheme, the following Chinese patented herbal products are recommended: [22] Obviously, TCM plays a crucial role in fighting against COVID-19.

Since the outbreak of pandemic, researchers have carried out a large number of clinical studies on TCM treating COVID-19, and thus providing valuable experimental evidence for summarizing clinical experience, discovering effective intervening measure, and optimizing clinical protocols. A clinical trial registry follow-up study [23] tracked Chinese Clinical Trial Registry and ClinicalTrials.gov as data source and its result showed that by April 20, 2020, there had been a total of 137 registered clinical researches related to using the TCM treatment against COVID-19 (including integrated Chinese medicine and Western medicine). The sample size was 58,266 and most of the researches were randomized controlled trial. Potential effective intervening measures included classical TCM prescriptions, Chinese patent medicine, TCM exercises, acupuncture, moxibustion, and Tuina, as shown in Table 2 .

With the deepening of TCM clinical research, a larger number of achievements have been reported. Statistics showed that by October 17, 2020, newly included literature on TCM treating COVID-19 by SinoMed and PubMed were 1,780, among which 160 were evidence-based ones. These theses covered clinical observation, controlled trial, and randomized controlled trial, as well as systematic review based on clinical trial. [24] [25] [26] Researches on traditional Chinese medicine characteristic theories From the perspective of TCM, the qi of cold-dampness and pestilence obstructs the spleen and stagnates the lung, Chest relieving and regulating technique, tuina 2 TCM: Traditional Chinese medicine enters from superficies to interior and transforms itself into heat. These are the clinical features of COVID-19. Hence, resolving dampness and removing toxicity can be applied with strengthening body resistance and eliminating evil simultaneously. TCM therapies are mainly applied to patients with mild and common types. Decoction or Chinese patented medicine is used together with auricular point pressing with bean to quickly alleviate symptoms and hold the progression of disease at bay, so patients can be cured clinically. For severe and critical patients, integrated Chinese medicine and Western medicine therapies were applied to rescue them. TCM puts emphasis not only on strengthening the body resistance for relieving depletion, purging the lung to relax bowel, but also on removing toxicity, nourishing yin, and inducing resuscitation. Academician Zhong Nanshan pointed out [27] that "the present clinical practice has proven the objectivity and effectiveness of TCM. The modern medical study methods should be adopted to better interpret and explain TCM, so that recognition can be gained from both domestic and international medical colleagues." Chinese researchers Wang W et al. [28] analyzed the therapeutic schemes for COVID-19 and prescriptions of TCM in relevant clinical cases across the country, discussed prescription patterns on preventing and treating COVID-19, thus providing reference for the clinical prescriptions and medication. Data mining was adopted by Bai M et al. [29] to sort the prevention and treatment of epidemics in ancient books. They set up a database of prescription formulating, explored potentially valid herbal pairs and their compatibility, thus offering new ideas for the clinical application of Chinese medicine. Modern medical researches focus more on commonalities of diseases when developing drugs, but when individual factors dominate, there will be poor treatment response. On the country, TCM takes holistic concept and syndrome differentiation as the principles, attaching full importance to individual factors, so its targeted treatment can achieve good results. However, due to individual differences and environmental factors, it is difficult to repeatedly test on the same prescription; hence, the curative effect of specific prescriptions cannot be guaranteed or promoted. In addition, TCM experiment and fundamental research are rather backward and have impeded its development. We should strengthen the basic research, lay emphasis on the type of syndrome, pathogenic characteristics and evolvement of disease, and find specific medicine and prescription for specific disease based on the above emphasis. To achieve better therapeutic effect, clinicians should modify and adjust these specific medicine and prescription according to the individual conditions of patients.

Facing the outbreak of COVID-19, Chinese medicine and western medicine can join hands and build a solid lifeline of defense, and this is a highlight of epidemic prevention and control in China. At present, the situation is generally under control, but the novel coronavirus is to be wiped out yet. The nationwide virus control is now being conducted in an ongoing normalized basis, for a long time. "In this fighting against COVID-19, TCM has played a crucial and all-round role in the overall process of prevention and treatment," said Zhang Boli, the academician of Chinese Academy of Engineering who continued thus: "TCM will always prevail as long as an opportunity is given. The virus is new in each epidemic, and there is no specific medicine available, so I think TCM should take responsibility upon itself." [30] Although the epidemic is now generally under control, the virus is borderless. Now COVID-19 still wreaks havoc on a global scale and multiple outbreaks have been reported. Wu Zunyou, the chief expert of the Chinese Center for Disease Control and Prevention, predicted that COVID-19 will maintain high prevalence for the indefinite future, and even aggravate in winter. [31] Recently, a piece of news about Timoshenko, the former Prime Minister of Ukraine, has circulated online. She said she would actively promote the internationalization of TCM. [32] In August 2020, she was infected with COVID-19, and then fully recovered with the help of integrated Chinese medicine and western medicine therapy. This is an epitome of many stories about TCM fighting against COVID-19 outside China. As a part of the outstanding traditional Chinese culture, TCM culture is rooted in the ancient civilization of our country. To better spread the classical theory of TCM, we should combine it with time-honored history and civilization of our nation. We can also promote TCM culture to people outside of China from the dimension of history, humanities, folk customs and geography, and elaborate the mechanism of TCM treatment via fundamental researches. The internationalization of TCM needs both humanities and science. As the leader of NATCM expert group for medical rescue, Huang Luqi, the academician of Chinese Academy of Engineering, president of the China Academy of Chinese Medical Science, said, [33] "We would like to fight side by side and jointly response to the pandemic with people from all the countries. We are willing to share TCM experiences and achievements against COVID-19!" Translator: Guoqi Shi (石国旗)

This study was financed by the grants from National Key R&D Program of China (No. 2019YFC1709803) and National Natural Science Foundation of China (No. 81873183).

None.

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