key: cord-0921200-82wbcdpy authors: Iranzadasl, Maryam; Karimi, Yasin; Moadeli, Fatemeh; Pasalar, Mehdi title: Persian medicine recommendations for the prevention of pandemics related to the respiratory system: a narrative literature review date: 2020-07-25 journal: Integr Med Res DOI: 10.1016/j.imr.2020.100483 sha: 55d2b03da19e358ee21a1b1b11a254be0be27275 doc_id: 921200 cord_uid: 82wbcdpy BACKGROUND: Pandemics of infectious diseases have long been regarded as societal challenges. This study aimed to summarize the theories of Persian medicine for controlling respiratory disease-related pandemics and to compare these theories with the findings of modern medicine. METHODS: We searched the classic medical reference books of the 9th to 19th centuries for the terms ‘polluted air’ and ‘pandemic’, and we searched 4 databases (PubMed, Google Scholar, Science Direct, and Scopus) with the keywords ‘COVID-19’, ‘pandemic’, ‘history’, and ‘prevention programs’. The results were collected and subjected to content analysis. RESULTS: From the point of view of traditional Iranian physicians, disease prevention is primarily possible by avoiding pathogenic factors. As a secondary solution, reducing one's susceptibility to the disease is crucial; this can be achieved through cleansing the body and strengthening the mood, reducing food intake, decreasing the internal humidity, disinfecting the house with herbal fumigation, and making use of pleasant aromas. Some of these recommendations are reaffirmed by modern research. CONCLUSION: Persian medicine techniques may be preventive during respiratory, influenza-like disease pandemics. However, rigorous studies are needed to confirm this hypothesis. Throughout history, many reports of pandemics have been recorded, with respiratory infections such as influenza being among the most notorious and common 1, 2 . In the earliest documents, historians reported the occurrence of an influenza-like pandemic in Greece in approximately 412 BC 2, 3 . In each of the recent centuries, an average of two to three influenza pandemics have occurred worldwide 4 . The geographic and political conditions of Iran have led to its involvement in a range of pandemics throughout its history 5 . Due to Iran's involvement in most global pandemics, related topics, especially respiratory infectious diseases, have remained prominent aspects of Persian medicine (PM). Accordingly, Persian physicians are familiar with respiratory, influenza-like pandemics, discussed under the title 'polluted air' (PA; háwāy-e vábāī) in reference books 6 . Avicenna considered vábā to mean a general disease, i.e., the pandemiclike spread of a disease 7 . In fact, under PA conditions, various diseases such as smallpox, typhoid, plague, and various fevers and abscesses arise; symptoms such as fever, dyspnea, palpitations, and syncope results in a considerable number of deaths in the community 8 . Regarding pandemic respiratory infections with specific symptoms, terms such as 'polluted wind', 'postnasal drip related to common disease', 'fever related to common disease', and 'cough related to common disease' have been used in the Persian references 9, 10 . The coronavirus disease 2019 (COVID-19) pandemic has affected most countries across the world. The symptoms induced by SARS-CoV-2 virus are vastly similar to those of other viral infections of the respiratory tract (e.g., influenza) 11 . The person-to-person transmission of this virus has facilitated the rapid, global spread of the disease 12, 13 . Considering the fact that an effective modality of treatment for this newfound ailment has yet to be discovered, there is a significant need for preventive policies and the utilization of experiences from traditional medicine 14 . The present study aimed to review the theories, experiences, and views of Persian medicine scholars and compare them with the findings of modern medicine for controlling respiratory disease pandemics. In addition, the main medical databases, i.e., PubMed, Science Direct, Scopus, and Google Scholar, were searched for the terms 'COVID-19', 'pandemic', 'history', and 'prevention programs'. Data published prior to April 2020 were collected, and modern and traditional information was analyzed and compared. First, we gathered all notes and documents to form a comprehensive file on a computer. Then, we reviewed the findings several times and made notes about relevant information. We made some initial codes to categorize the data into historical, preventive and incoherent groups. Subsequently, the recurring codes and items were combined into cohesive themes presented in text and tables. J o u r n a l P r e -p r o o f We gathered relevant data from the historical references and from a total of 1342 papers indexed in the electronic databases to form a one hundred twenty three-page Microsoft Word document. After a thorough review of the searched material, we finally reached a six-page dataset composed of the most applicable information from both the classical books and 64 novel articles. In PM references to control PA conditions or the occurrence of pandemics, numerous recommendations have been issued for health preservation management via the six essential principles as well as the nonessential principles 15, 16 . However, Persian physicians consider distancing from the disease area and self-quarantining at home to comprise the first and foremost preventive strategy 17 . Subsequent to the six essential principles, other factors, such as showering and oiling the body, are considered nonessential principles that also have significance in pandemic disease prevention 15 . The first and foremost method to prevent the incidence of disease during pandemics is to move from the focus of the disease to healthy regions. However, as a secondary solution, it is necessary to self-quarantine in closed environments such as the house and to correct the internal environment 17 . Among the principles of correcting the internal environment is the removal of moisture using the incense of plants such as purple nutsedge (Cyperus rotundus), frankincense (Boswellia carterii), myrtle (Myrtus communis), Damask rose (Rosa damascene), sandalwood (Santalum spp.), and vinegar 7, 15 . Another measure to correct the internal environment is to dissolve the Ferula asafoetida in vinegar and spray it several times inside the house and at its entrances (e.g., doors and windows) 17 . Avicenna also introduced the use of vinegar as a deterrent of PA 15 . Hunger and thirst are harmful to both healthy people and those afflicted with pandemic disease, as they augment the effect of PA 17 . On the other hand, drinking plenty of fluids is not recommended in PM 15 . In addition to reducing food intake (as the most prominent food strategy), measures such as increasing the number of meals, reducing the size of each meal, and consuming easily digestible foods should be considered [18] [19] [20] . Eating sour and drying foods such as sour grape soup, pomegranate soup, sumac soup, and vinegar soup is also beneficial 17, 18 . Another recommendation is to consume fragrant fruits such as apples (Pyrus J o u r n a l P r e -p r o o f malus) and quinces (Cydonia oblonga) as well as sour/astringent fruits such as pomegranates (Punica granatum) 8, 18, 19 . In PM, during epidemics, high-intensity exercise or activities that result in shortness of breath are considered harmful and are therefore prohibited 7, 19 . The balance of evacuation (excretion of waste products) and retention (preservation of beneficial substances) should be maintained in such a way that while excess moisture is eliminated, weakness and reduction of vital force do not occur. Generally, sleep should be considered in terms of two aspects. The first is the sleep duration, which should be moderate, i.e., between 6 and 10 hours per day. The second is the timing of sleep, such that one should refrain from remaining awake through the night, sleeping late, or sleeping during the day. Avoiding mental conditions such as sadness, anxiety, emotional stress and anger can be effective in preventing the incidence of disease during PA 18 . Refraining from obsession is also essential and necessary 19 . It is highly remarkable that, as evident in Table 1 , the PM recommendations maintain a high level of agreement with the WHO guidelines for dealing with COVID-19. There is some current evidence in support of the anti-infective properties of the Persian medications recommended for preventing PA in traditional resources (see Table 2 ). Current sleep research and guidelines also confirm the beneficial effects of adequate sleep on the immune system 27 . The necessity of social distancing during the peak of a pandemic, which includes restrictions on exercise (particularly team sports), has been reaffirmed recently 22 . Furthermore, the incense of agents such as vinegar and sandalwood can minimize ambient humidity. Research has shown that the COVID-19 spreads more prominently in areas with a humidity of 47-49% 28 . The positive impact of reduced fear, stress and anxiety on the body's immunity and physical strength has also been confirmed in recent studies 29 . J o u r n a l P r e -p r o o f Discussion After examining and analyzing the findings of the present study, it can generally be inferred that PM considers the issue of prevention in the context of pandemics from two perspectives. First, it considers the etiological agent of the disease and recommends its avoidance by refraining from the area of outbreak or self-quarantining at home. In fact, this is the first and foremost recommendation of Persian physicians. The second substantial factor that should be considered is the background and susceptibility of individuals to the disease, with the risk of affliction being largely minimized if the suggested measures are taken. It should be noted that this susceptibility is broader than the issue of comorbidities mentioned in modern medicine because, from the perspective of PM, individuals who appear to lack any underlying conditions can be quite susceptible to infectious diseases. This is consistent with recent studies that have reported healthy subjects becoming severely affected by COVID-19. Among the six essential principles, Persian physicians have placed greater emphasis on nutrition, air, and the excretion of waste products from the body, causing weight loss. Hence, obesity can increase the risk of acquiring influenza disease in the community 46 . Novel studies have demonstrated that calorie restriction (CR) affects various parts of the immune system and improves its function 47 . Currently, many studies have hypothesized that the olfactory system influences the immune system 48 . Accordingly, essential oils are also used in aromatherapy given their antimicrobial, anti-inflammatory, and immune system-enhancing properties [49] [50] [51] . Garlic is one agent that boosts the functioning of the immune system in such a way 44 . Another example is the onion, which should be eaten or inhaled during steam therapy according to a PA-related recommendation of PM. As a novel finding, the cardiac symptoms in COVID-19 patients 52 may be related to the PM theory of cardiac involvement during PA. Such issues must be examined in detail to be proven or disproven in future research. Furthermore, the loss of the smell and taste senses in many patients with COVID-19 53 may be related to PM physicians' emphasis on the use of fumigation therapy with fragrant plants; this can form the basis of studies on the effects of these substances on stimulating the olfactory system and recovering the senses of patients, which is a promising sign during treatment. In the current pandemic, due to the ease of person-to-person transmission and the rapid, The main limitation of the current study is the difficulty of exploring causality because it is based on beliefs and judgments rather than outcomes. Additionally, the statistical representation of findings is not applicable here, rendering this work difficult to replicate. Some mentioned medicines and practices such as fumigation and embrocation seem safe to be utilized for decreasing the chance of infection in respiratory outbreaks. We also suggest conducting pilot clinical trials assessing the effectiveness of the fruits introduced in the PM literature (apples, quinces, and pomegranates) in treating antibacterial infections given adequate in vivo and in vitro evidence. In conclusion, no significant contradictions were found in this study between current guidelines for the control of pandemics and those of traditional Persian physicians. Therefore, it is essential to pay attention to factors that may currently be overlooked (e.g., nutrition, body cleansing, strengthening the temperament) and to assess the multifactorial and cumulative effects of these factors. Observe social distancing and personal hygiene (frequent hand washing, use of gloves and masks); trace suspicious cases [21] [22] [23] . Reduce food intake 19 ; consume antidotes 7 ; eat garlic, onion, and vinegar 17 ; consume sour foods 17, 18 and fragrant fruits such as apples and quinces 18 . Wash and disinfect food products (no specific diet); avoid drugs and alcohol 21, 23 . Avoid relatively high-intensity exercise 19 ; avoid excessive rest/immobilization 18 . Avoid group exercise/sport; take up appropriate, regular exercise during quarantine 22, 23 . Consume stool softeners such as the Terminalia chebula and Cassia fistula 19 ; avoid excessive sexual intercourse 18 . - Moderate sleep duration; sleep early at night and wake up early; avoid daytime sleep 19 . Have adequate rest and regular sleep 22 . Avoid harmful mental states such as sadness, fear, anxiety, stress and obsession 18, 19 . Reduce stress in the home environment 22, 23 . 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