key: cord-0984207-gvkn5041 authors: Adluri, Uma Shankar Prasad; Tripathi, Akash Chandra title: Understanding COVID - 19 pandemic – A comprehensive Ayurvedic perspective date: 2020-09-08 journal: J Ayurveda Integr Med DOI: 10.1016/j.jaim.2020.08.001 sha: 5256cf85398375aac63268740de1d6c4066fdac0 doc_id: 984207 cord_uid: gvkn5041 Epidemics have not been new to India. Ayurveda being in the fore front of health care of those times, has recorded its valuable experiences of epidemics & termed them as Janapadodhwamsa or Maraka. It has vividly described their mechanism of Causation (Nidana), factors affecting severity and actions complicating illnesses their management and prevention. The present work uses the same model described in Samhitas which assert the superiority of host susceptibility (Nija) over External Agent/Virus (Agantuja) and uses the same principles in prevention; while adopting the Jwara model to explain and correlate with different stages of COVID – 19. It proposes management guidelines using Ahara (Nutritional Principles) and Oushadha (Medication) for different stages and subsets of patients along with their potential complications and drug interactions, utilizing the principles of host factor modification (Dosha hara) and potential broad spectrum Anti-viral (Prativisha) as envisaged by Rasa Shastra. Towards to the end of 2019, a novel corona virus, now designated as Severe Acute Respiratory Distress or SARS e CoV-2, was identified as the cause of a cluster of pneumonias in Wuhan, Hubei province of China and has since spread rapidly to 213 countries affecting more than 11.8 million people worldwide and caused 5.44 lakh deaths till july 2020 it was designated as a global Pandemic by WHO in March 2020. The present Pandemic of COVID-19 has brought the so-called human activity to a standstill, and has forced the entire world to seek very seriously for its cause, mechanisms of pathogenesis and its solution. Ayurveda being one of the oldest surviving Medical Tradition, has a key role to play in this crucial situation. Epidemics have not been new to India. Ayurveda being in the fore front of health care of those times, has recorded its valuable experiences of epidemics & termed them as Janapadodhwamsa [1, Vimana Sthana 3/1e4] or Maraka [2, Sutra Sthana 6/19]. It has vividly described their mechanism of Causation (Nidana), factors affecting severity and actions complicating illnesses, their management and prevention. The present work uses the model of Janapadodhwamsa of Acharya Charaka and Maraka of Acharya Sushrutha along with the model of Masurika of Acharya Madhava [3, 54/3] to explain the Pathogenesis of COVID e19 with modern correlation. The study identifies it as Nija Jwara and Oupasargika Roga, proposes a Diagnostic Protocol based on Acharya Charaka's Jwara model, identifies factors affecting its severity or complicating its course, along with their modern correlation and proposes management guide lines for different stages and various subsets of patients; while describing the general contraindication of drugs, their potential interaction with concomitant modern medicines, criteria for selection etc. The study also identifies important preventive principles along with medications with aim to restore balance between man and nature. Current available evidence for COVID-19 suggests that the causative virus (SARS-CoV-2) has a zoonotic source closely related to bat-origin SARS-like corona virus but lab creation is being investigated. It is an enveloped RNA beta corona virus related to the Severe Acute Respiratory Syndrome (SARS) virus, and the virus has been shown to use the angiotensin-converting enzyme 2 (ACE2) receptor for cell entry. The persons infected by the novel corona virus are the main source of infection. Direct person-to-person transmission occurs through close contact mostly in closed indoor spaces, mainly through respiratory droplets that are released when the infected person coughs, sneezes, or talks. These droplets may also land on surfaces, where the virus remains viable. Infection can also occur if a person touches an infected surface and then touches his or her eyes, nose, or mouth. The median incubation period is 5.1 days (range 2e14 days). The precise interval during which an individual with COVID-19 is infectious is uncertain. As per the current evidence, the period of infectivity starts 2 days prior to onset of symptoms and lasts up to 8 days, the virus has a Basic Reproduction Number or R0 of 2e2.5 and serial interval of 4e5 days (as of may 2020) [4, 5] . The extent and role played by pre-clinical/ asymptomatic infections in transmission still remain under investigation. Clinical features include fever, cough, other upper respiratory symptoms, myalgia, diarrhea, loss of taste and smell, fatigue and dyspnea. Most patients with COVID-19 predominantly have mild a respiratory tract infection associated with SARS-CoV-2 infection. However, in a small proportion of cases, they can progress to a more severe and systemic disease characterized by the Acute Respiratory Distress Syndrome (ARDS), sepsis and septic shock, multiorgan failure, including acute kidney injury and cardiac injury. Autopsy findings in China and European countries showed endothelial damage of pulmonary vasculature, microvascular thrombosis and hemorrhage linked to extensive alveolar and interstitial inflammation that ultimately result in COVID-19 vasculopathy, pulmonary intravascular coagulopathy, hypercoagulability, ventilation perfusion mismatch, and refractory ARDS. Hypoxemia, secondary to ARDS may also activate the coagulation cascade. No Drug is known to be curative, although several are being studied extensively like Favipiravir, chloroquine, remedesvir, steroids like Dexamethasone and IL-6 inhibitors like toclizumab and convalescent plasma therapy etc. Prevention encourages diligent hand washing, practice of respiratory hygiene, avoiding of touching face, cleaning and disinfecting of objects frequently touched, ensuring adequate ventilation of indoor spaces, wearing of masks, avoiding crowds and close contact with ill individuals and Social distancing. Different vaccines are in different stages of development, with none available as of date. Both Charaka Samhitha and Sushrutha Samhitha described a fairly common Pathophysiology of Epidemics. In the context of COVID -19 the above concept is understood as follows: Adharma Activities of this kind vitiate and disturb the balancing forces of nature and gives rise to abnormal air currents, Cyclones, Floods, non-seasonal rains, extreme weather conditions etc. Destruction of Amazon wild forests or Destruction of Australian forests due to wild fire, Extreme weathers, non-seasonal rains experienced around Europe, Australia, India etc. can be taken as Aristas (warnings). The vitiation of air currents, seasons, seasonal irregularities and disturbance of land and water ecology simultaneously induces or leads to vitiation of doshas (Cytokines) in humans, causing mass susceptibility to the same illness, while also affecting the oshadhis (food yielding plants), thus reducing the nutritive value and leading to under nourishment. When this combines with the causative factors causing agni mandya (sluggish metabolism)' it leads to infectious diseases like COVID-19; probably more in future if corrective actions are not taken. The predominant pulmonary involvement of covid-19 can be explained by the commonality of pranavaha srotas vitiating factors with that of vata, [1, vimana sthana 5/10] (Kshaya-weight loss, vega sandharan-constipation, rukshata-low fat high fibre diet intake, vyayamat kshudhitasyainappropriate excessive exercise) and the increasing incidence of these in the present day life style Fig. 1 . COVID e 19 is taken as a Janapadodhwamskara or Maraka, Oupasargika Roga [6, Nidana sthana 5/19] (here Upa ¼ near, Sarga ¼ Produced due to proximity) or contagious disease; and following the model of Patho Physiology (Samprapti) explained by Acharya Madhava in Masurika (Smallpox), should be taken as a nija jwara (Endogenous Fever). Masurika (smallpox) model, is taken, as it shares the characters of being a pandemic, viral infection spreading through respiratory route, highly contagious etc. with COVID -19. Although many authorities have suggested COVID to be accepted as Agantuja (Exogenous), the authors differ from this opinion for the following reasons, discussed under two headings. 3] Adrisya krimi is described only in raktaja krimi, where its clinical features of loss of body hair, ulceration or necrosis of muscles, tendons etc are never seen in covid 19. Hence we conclude that as far as ayurvedic perspective of respected Acharyas is concerned it cannot be accepted in any known agantuja cause, unless we propose it as a newer development. In reality the difference lies in the fundamental difference that defines approach to fevers between modern medicine and ayurveda. Modern medicine has always looked for a cause from 'outside' basing itself on the 'GERM HYPOTHESIS 0 , while ayurveda has always looked 'inwards' and feels it is Doshas or NIJA hetu that cause all these fevers. Ayurveda believes that even if there is a virus or bacteria, until there is no vitiation of doshas primarily in the body, none can infect the human system in a way that it manifests as disease. This fact is accepted by modern medicine in the context of tuberculosis, that although there is an infection, disease can happen only if immunity is weakened; and in Sepsis which is deemed to happen, not due to an infection, but only when the host mounts a Dysregulated immune response. Hence we believe that although modern medicine may feel that Covid is caused by a virus, from a classical ayurvedic perspective while it is completely acceptable; but it should be taken as secondary, and primary importance should be given to host factors or NIJA doshas or increased mass susceptibility only, in the manifestation of the disease. This is exemplified by the fact that although same virus is causing the disease in all, some are asymptomatic, most have mild symptoms and only a few have severe disease; which we feel strongly is due to the status of doshas in them. Particularly the asymptomatic infections highlight the concept of viral infection in a subject with Dosha Samya, and underline the importance of doshic vitiation as the primary determinant of disease manifestation, not just an infection. Increased mortality in patients with co morbidities also suggest the role of doshic vitiation as the primary determinant of disease severity. Although the vitiation of Vayu, Jala, Desha, Kaala (Rutu) and ahara induce the formation of specific doshas in all, leading to mass predisposition or mass susceptibility of the diseases; In the case of COVID -19 an imbalance of Vata & Kapha; The people indulging specifically in a Vata -Kapha provoking Ahara Vihara, at Vataja extreme of age (elderly), or Vataja & Kapha Vikara like hypertension, COPD, Bronchial Asthma or Dhatu or Ojo Kshaya (Immuno-compromised) are found to have a more serious disease; underlining Doshic importance. Hence we conclude that Covid -19 from an Ayurvedic perspective should be taken as a NIJA Jwara and Oupasargika Jwara. Correlating the clinical features described by various authorities [9] the symptoms of COVID-19 mostly correlate with Vataja or sometimes Vata Kapha Jwara usually in a Saama avastha. It is the Aama which may provoke pitta and kapha at a later stage making it a Vatolbana Sannipata in the more advanced stages. The severity in Sishira rtu (in china) & Vasanta Rutu (in Europe and U.S) and mild course of illness in hot weather and severe surge in rainy(in India) also point to the same. In fact the understanding of vata as per Ayurveda explains this seasonal variation although many studies felt that increasing relative humidity is detrimental to the virus alone [10] . Hence summarizing the causative factors or Nidana we can conclude the following: But it should be noted here that in the later stages, after the development of the Rasa sastra, that the later Acharyas felt a strong resemblance in the Pathophysiology of fever, to the Pathophysiology of Visha, and started the use of poisonous plants or minerals (both are sthavara visha) as a counter (Prativisha) to the toxic effect of fever in humans (Jangama Visha) acts as Anti-bacterials/Anti-Virals. It is not a simple coincidence that modern medicine did the same by giving a fungal poison (Sthavara Visha) penicillin, to bacteria (Jaangama) in the 20th Century: heralding the era of Antibiotics. COVID has exhibited various patterns as per various authorities. These are discussed or identified in Ayurveda as follows. Any of the above features along with the manifestation of Ama leads to -Saama -Avastha in most fevers due to reduced Agni in Amasaya (upper GIT & Liver) the Rasa Dhatu is partially digested and produces an intermediate product called as Ama, having Guru (heavy), Visra (foul smelling), Ati Picchila (sticky) Guna leading to Sroto rodha. This Ama can be deemed to be the chief source of inflammatory cytokines or the food for the viruses and bacteria, and the source of Auto Immunity in chronic state Tables 1, 2. Although the virus is the same, it ranges from Asymptomatic or mild infection, to critical disease in different subjects. This variation is due to host response. The cause for severity of the host response is explained in Ayurveda as follows [ The resultant fever is severe and continuous and called as Santata Jwara and it follows a different and more aggressive course. In The ARDS in COVID-19 has attracted worldwide attention due to its peculiar pathophysiology of microvascular thrombosis to frank Thromboembolism. According to Ayurveda this reflects an increase in stickiness (Picchila Guna), mostly due to Ama[3, 25/ 1e5]. rather than Kapha, which along with Vata Dosha leads to These actions prolong or intensify or complicate fever and hence are to be avoided, particularly during first 7 days of Fever. Pain/arthralgia e Parvanam Bheda. Lassitude -Aalasya Constipation with hard stools -Gadha Vidkata. Generalized heaviness -Gauravam Heaviness e Guru Gatrata Excessive somnolence e Nidra. Excessive somnolence -Tandra All fevers in Saamavastha will need a Judicious Langhana protocol except pure Vataja Jwara, or patients with poor nutritional status; while taking care of hydration and hemodynamics. Based on severity of Amavastha which can be grossly correlated with appetite. No appetite, with Nausea or vomiting e fasting till appetite appears (with or without iv fluids). Very mild appetite with no Nausea and vomiting e Ganji (rice gruel or chaavalmaand) or hot thin soups. Moderate appetite -ideally Yavagu; alternatively rice or wheat porridge (thin upma). If patient has normal appetite; diet will consist of soft rice with moong daal with or without rasam, or pulka with moong dal and oil free sabji. No curd, milk or raw foods or fruits or non-vegetarian foods are to be given; although nonvegetarian soups (rasa)are permitted and considered useful in vata jwaras. The intake of snehas processed with deepana pachana dravyas like ginger etc should be encouraged after completion of amavastha with good apetite(agni) and lightness in the body to pacify the vata dosha. Hot water e ushna jalapana/Boiled and cooled water. Paniya e made with panchakola should be used for initial management in both phases. Shadangapaniya is given in pitta predominant patients. 50 gms (Tiksna Dravya) or 200 gms (Mrudu Dravya) is added to 3.2 L of water and boiled to 1.6 L, to this 1/6th (250 gms) of rice is added and cooked. Same medicines as the above but in full doses. In Atyayika condition (emergency) Muhur eMuhur prayoga[13, volume1, sutra sthana; 13/39e40] (frequent dosing) is suggested: Churnas are given in dose of 3e4 gms in multiple doses up to 12 gms/day. While Sudarsana churna may be given as a Phanta Kalpana. Kasayam dosage depends upon the method of preparation. Aristas are given up to 50 mL/day. Except Kanakasava which is given at 5e10 mL per dose twice daily. Dose of Rasasindoora with navasadara is 60e180 mg/day while Rasasindoora without Navasadara 125e500 mg/day and Malla sindoora e 60e120 mg/day. All Vatsanabha containing preparations have a potential to interact with HCQS & Azithromycin or other QT-Prolonging drugs. As purified Visha is known to cause Bradycardia in high doses and may worsen the QT Prolongation [21] . Hence caution to be used in terms of close monitoring of ECG if concomitantly used; All Pippali containing preparations are known to augment the drugs of other modern medicines [22] . Hence care should be taken in use of potentially toxic medications; Possible interference with anti-coagulation, with potential to increase PT/APTT with all ushna, tiksna Preparations. Hence ideal to use Unfractionated Heparin rather than LMWH and monitor PT/APTT closely in case of concomitant use; Increased incidence of Hypoglycemia possible with concomitant use of Sudarshana churna, Guduchi, etc with HCQS and other Glucose lowering agents [23] ; Possibility of increased hepatotoxicity/nephrotoxicity on concomitant use of Remedesvir and Favipiravir with Ugra/Ushna veerya drugs. Dosha Pratyanika e Specific for Dosa with Guna; Vyadhi Pratyanika -Specific for disease with avastha; MukhyaDravyaViseshatvam -Specific characteristics of chief ingredients; Prakarana Viseshatvam e Described in the concerned chapter only; Acharyokta Visesha Kaarmukatvam [14] eChief indications prescribed by Original Acharyas; Vruddha Vaidya Anubhava Viseshatvam e Experience of Vaidya's in earlier Pandemics; Dravya Nishedhatvam e Contraindication of a Drug mentioned by previous Acharyas; Potential side effect/interaction with concomitant medication; Sweeya/Pratyaksha Anubhava -personal experience; Use of medications ideally prepared before the onset of Pandemics. Example: -Arishtas, Rasa Oushadhas. As COVID-19 is presumed to involve the following key players in its pathogenesis, prevention aims at the reversal of the same. Vata Dosha; Sannipata; Ama Utpatti; Sakha Gati; Prana vaha Sroto Dushti; Adharma-Prajnaparadha (Table 3) . It is ideal to do Panchakarma or At least Kunjal and Mridu Virechana (Kosta Shuddi) before starting medicines as per one's own Prakruti, Agni Bala and overall health status. The following can be used. Hence Ayurveda advises us to practice Dharma in the form of. & its controlling energies, through the principles of Snehana of Prapanchika Vaayu through Vaidika Agni to restore the dynamics of air currents. 6. Brahmacharya: -Self-control& seeking of Spiritual happiness 7. Dedication to Spirituality 8. Prayaschitta: -Actions undertaken to undo the wrongs towards nature and Life forms, with a view to repair Man's Relationships with Nature and to help Nature in Healing Itself from the ravages of overexploitation caused by our Civilization & to rediscover living and growing in harmony with Mother Nature. The present proposal is based on classical understanding of Ayurveda and it needs to be emphasized that as of date there are no known curative medicines for this virus. Hence this approach has to be applied pragmatically, taking into consideration various aspects, like a proper evaluation of the individual patient based on Ayurvedic parameters, with due advice and inputs from the colleagues from Modern medicine, proper discussion in a integrative scenario of possible drug to drug interaction and limitations of therapy, ones own experience with usage of particular drugs, with proper preventive contact and respiratory precautions in place, and results being documented systematically particularly when dealing with sick patients and critical conditions. But we strongly feel that Covid-19 presents a very valuable opportunity for Ayurveda to join hands with Modern Medicine and enrich itself and Science in general for betterment of Mankind. As the number of severe COVID Positive patients directly studied by the authors is limited and very little attention has been paid to the details of clinical symptoms across different studies, need to study clinical presentation in larger subsets of patients to draw more specific conclusion. Hence may need to update the guidelines as numbers/understanding of the disease increases. The Authors have no conflicting interest to disclose. This Research did not receive any Specific grant from funding agencies in the Public, Commercial or Not for Profit sectors. if Swasa (SOB), Kasa (Cough) dominant or Santata Jwara Kasayam /200] (kalingaka, patolapatra katurohini) If fever is Dominant Tribhuvana kirti (if fever dominant) (up to 500 mg/day) alternatively Sanjeevani vati Or Swasa kuthar rasa Ras if Kaphaja Kaasa Pradhana(Productive cough with thick mucoid sputam) (60e120 mg/day) e any one of these medicines are to be used based on the conditions along with above Jayamangala rasa e (if Rogi Bala is low ARDS (Swasa Pradhana VataKapholbana sannipata) DasamulaKatutrayadi kasayam Any One of the following in each section based on patient's condition: Dasamularishtam[8, JwaraAdhikarana: 74/341 (if dry cough) or Vasakasavam Rasasindoora [15]with anupana of pippali churna 1e3 gms or sitopaladi churna 3e5 gms Vata Kapha Pradhana)/Mallachandrodaya or Mallasindoora Amritarishtam/Vasakasavam/Dasamoolarishtam (any one); (4) Tribhuvana kirti/Swasakuthara ras (any one) (upto 500 mg/day); (5) Samira Pannaga ras Malla Chandrodaya or Mallasindoora (kapha dominant); (6) Poornachandrodaya Makaradwaja (60e120 mg/day Septic shock [Considered as Asadhya (incurable) in Samhitas, but was attempted to be treated after development of Rasa Shastra only the following medicines are described for usage in the last phase(antim avastha) of sannipata jwara for hrudaya-fuffusanadimandal uttejana (cardiac-pulmonary and CNS stimulation). As definitive intestinal absorption is poor at this stage Verse 2748] -60e125 mg 6th hourly, sub-lingually 642e649] -2e4 mg over scalp incision along with 2e4 mg orally with butter; jwara (Chronic fever -more than 10e12 days of fever) Indukanta Ghritam Jaya Mangala Ras (250e500 mg/day) OR Suvarna Vasanta Malati (250e500 mg/day) Special considerations If Elderly, Emaciated, COPD or Asthma or Structural lung Disease, LVF, Immunosuppressed, Hypertension, Diabetes Mellitus. Drugs of clinical stage protocol with any one or two of the following Naradiya Lakshmi Vilasa ras Dasamula Arishta Recurrent respiratory infection/atopic Individual:In addition to the jwarahara medicine need to add one or more of the following Bilwadi gulika Uttara sthana Shireeshaarishtam/Shireeshaadi Ghana vati; Kaphakuthar ras(125e250 mg/ day) Pregnant women and lactating mothers Amrutottaram [14 Kashaya Prakaran: 6th Kashaya]/Vyaghradi Kashayam Simple Vata Kapha hara Jwara Kashayas for mild infections Pippali Kwatham If all three doshas are involved (Vata Kaphaja with pitta anubandha) (ex: vatakapha jwara with APD/in Pitta prakruti/with hemoptysis/purulent sputum) Vyaghradi Kashayam & Dashmoola Kashayam; Churna: -Sudarshana Churna kalpas; Aristham:-Amrutaristha; Rasaoushadhi:-Jaya Mangala Ras Use of Vasa Kalpas (Vasa Swarasa, Vasa Guduchyadi Kashaya, Vrisha Ghritha [14, Ghrita Prakarana, 12] or Vasa Ghritha Portali Rahasya of Hiranya Garbha Portali case of Vata with Pitta. References Charaka Samhita of Agnivesha Sushruta Samhita of Sushruta Madhava Nidanam of Madhavakara. Varanasi: Chaukhambha Orientalia Sushruta Samhita of Sushruta Charaka Samhita of Agnivesha Bhaishajya Ratnavali (Sanskrit).1 st ed. Varansi:Chaukhamba Surbharati prakashan Presenting characteristics, comorbidities, and outcomes among 5700 Table 3 Don'ts: -Avoid Do's diet (eating as per appetite) Fasting/weight loss regimen Balanced/Moderate diet as per season/Health Bitter (bitter gourd), Astringent (Bengal gram) etc Boiled with coriander seeds -If summer like weather or hot constitution Inter meal snacking 6. Boiled with ginger if cold weather Excessive Tea/coffee/Nicotine/Alcohol 7. Timely sleep Heavy & excessively fatty foods. 8. Light exercises -to half of one's Capacity 9 Meditation/Prayer 11. Excessive sex 11. Relaxed mind Day sleep immediately after heavy food 12. Observence of Dharma (protecting nature) 13. Constipation 14. Late night awakening Exposure to unseasonal weather Excessive anxiety/depression, lust. patients hospitalized With COVID-19 in the New York City area Effects of temperature and humidity on the daily new cases and new deaths of COVID-19 in 166 countries Churna Kalpana: Chapter 6, verse 26e36. Varanasi: Chowkhamba Sanskrit Series Office Ras Tantra Sar Va Siddha Prayoga Sangraha (Hindi) Ashtanga Hridaya of Vagbhatta Varanasi: Chowkhamba Sanskrit Series Office Pottali Rahasya Prakaranam of Hiranya Garbha Portali BasavRajeeyamu (Sanskrit) Varanasi: Chowkhambha Sanskrit Series Office Vatsanabha: an agada perspective An appraisal of the bioavailability enhancers in Ayurveda in the light of recent Pharmocological Advances Antidiabetic claims of Tinospora Cordifolia (Willd.) Miers: critical appraisal and role in therapy Director &Chief Consultant of Sri Sarada Ayurveda Vaidya Sala The Authors Acknowledge the contributions of Dr. Sai Gowtham Deevi BAMS, MD, Ayurvedic Physician, Kollur Guntur (Dt), Andhra Pradesh. Dr. G. S. Rajyalakshmi BAMS, RMO, Raja Rajeswari Ayurveda Medical College & Hospital, Humnabad, Bidar(Dt) Karnataka. In helping to make the paper presentable with their extreme hard work and dedication.