key: cord-1039502-y4hi15l2 authors: Dornala, Sathya N.; Ayyagari, Raghuram title: Guidelines for safer panchakarma practice in non-covid clinical care during corona pandemic date: 2021-06-13 journal: J Ayurveda Integr Med DOI: 10.1016/j.jaim.2021.03.008 sha: c40d6aeae900588fc274980afdc583d08cebf246 doc_id: 1039502 cord_uid: y4hi15l2 Morbidity and mortality statistical trends of COVID-19 pandemic reveal that, “The coronavirus may be with us for a long time, and we have to learn to live with it rather than hope to vanquish its threat”. Considering these trends, it is imperative to make changes in our lives at home and workplace so as to prepare ourselves to face and protect the community at large from the risk of infection. Human interaction is necessary in healthcare particularly in panchakarma due to which panchakarma practitioners are in a dilemma about how to start their services in the non-covid cases and how to protect the patients and hospital personnel from the possibility of exposure to COVID-19 infection. With this background, preliminary guidelines have been formulated as an aid to resume the panchakarma procedures. This guideline highlights the specific measures needed to protect occupational safety and quality in healthcare services in the area of panchakarma practice amid the COVID-19 pandemic. Currently, the world is facing a dual burden of diseases e one is non-communicable diseases such as diabetes mellitus, hypertension, chronic obstructive pulmonary disease etc., while the other one is of novel communicable diseases such as SARS-CoV, SARS-CoV2, Zika, Ebola, Nipah virus etc. It is a known fact that Ayurveda, particularly, panchakarma has a definitive role in the management of chronic non-communicable diseases [1] . Panchakarma is an important and unique specialty of Ayurveda; basically it is a bio-cleansing regimen (shodhana karma) intended to eliminate the disease causing toxic elements from the body thereby maintaining the homoeostasis of doshas. It is applied in deeprooted chronic diseases as well as seasonal abnormal imbalance of Tridoshas [2] . The panchakarma department in any Ayurveda hospital is an important clinical unit, as it offers services to many patients referred from different clinical departments of the hospital, performs the procedures as advised by the treating physician and after completion of the therapy, sends back the patient to the treating doctor. Morbidity and mortality statistical trends of COVID-19 pandemic reveal that, "The coronavirus may be with us for a long time, and we have to learn to live with it rather than hope to vanquish its threat" [3] . Hence, we should make changes in our lives at home and workplace so as to be prepared to face and protect the community at large from the risk of infection. Ongoing uncertain situation of COVID-19 reminds us about the basic premise of the management i.e. 'prevention is better than cure', because viral diseases are hard to cure and once contacted, they can be life-threatening. Considering the gravity of the corona pandemic, it is apt to say that prevention is the only and ultimate measure to contain the spread of COVD-19. Since the day of Janta curfew on March 22, 2020 in India [4] , all the activities related to panchakarma in various health centres and hospitals across India have been shutdown till date. However, its time to resume activities related to panchakarma since the lockdown rules and relaxations in the public movement have been eased. Human interaction is necessary in healthcare particularly in panchakarma; however, panchakarma practitioners are in a dilemma about how to start their services in the non-covid cases and how to protect the patients and hospital personnel from the possibility of exposure to COVID-19 infection. With this background, preliminary guidelines have been formulated as an aid to resume the panchakarma procedures. These guidelines highlight the specific measures needed to prevent nosocomial COVID-19 infections, and to protect occupational safety and quality in healthcare services in the area of panchakarma practice amid the corona pandemic. 3. Panchakarma siddhi ashtakam (eight aspects of panchakarma practice) The word 'siddhi' implies successful administration of panchakarma in non-COVID cases during the ongoing pandemic without getting infected with the infection. The word 'ashtakam' implies eight aspects which are related to panchakarma practice. Panchakarma siddhi ashtakam are depicted in Fig. 1 . Specific guidelines have been detailed with respect to these eight aspects - Daily sanitization of the panchakarma theatre with sodium hypochlorite solution [5] as per the standard practices. Sodium hypochlorite, commonly known as bleach, is most frequently used as a disinfecting agent. It is a broad-spectrum disinfectant that is effective for the disinfection of viruses, bacteria, fungi, and mycobacterium [6] . Dhupana karma e this medicated fumigation may be continued throughout the corona pandemic. Aparajitha Dhoopa choornam fumigation prevents the spread of infectious fever and also disinfects the air from pathogens. The antimicrobial activity of Aparajitha Dhoopa choornam has also been established [7] . Lighting of ghee lamps e It purifies indoor environment due to its visha grahadi bhutaghnam effect or you may use beewax candles (bhutaghnam). This can be practiced on regular basis especially during the pandemic. Display the infographics related to prevention and protection from COVID-19 inside and outside the theatre. Information related to techniques of hand-washing should be displayed at every point of hand-washing. Floor of the panchakarma theatre should be cleaned with antimicrobial liquid after attending every patient of panchakarma. Washrooms attached to the theatre and common facility area should be cleaned and sanitized after every use, irrespective of by the patients or staff, so as to avoid the transmission of corona from urine and faeces [8] . Common facility areas of high-touch surfaces related to panchakarma should be cleaned frequently. Doorknobs and handles may be coated with 'copper foil' or doors may be fitted with 'foot-operated door opener' wherever possible so as to avoid contamination due to frequent touching. Automated panchakarma equipment is an ideal choice during COVID-19 pandemic so as to maintain physical distancing to a maximum extent. Droni should be cleaned with herbal liquid soap or herbal handwash liquid after attending every patient. Copper utensils are advisable for the use in panchakarma. Disposable paper cups may be made available for drinking water. Use of dustbins having the proper lid. Panchakarma medicines which are being used successively for 3e7 days in the case of shirodhara, sarvangadhara etc. should be properly covered to reduce any chance of contamination. Medicines preparation area (kitchen) should also be sanitized and cleaned regularly and frequently. Physician must and should obtain written and signed consent from patient [9] for whom you have advised panchakarma that, he/she or their family members have never tested positive for COVID-19, his/her residential area has never been declared as containment zone (supported with aadhar address proof), he/she will report whenever patient suffers from fever or any other typical or atypical symptoms of COVID-19 and assurance from the patient he/she will not participate in any gathering of more than five people. Panchakarma specialist must follow social distancing and masking to prevent transmission to/acquiring infection from other healthcare workers who may be asymptomatic carrier. Advise patients to come for panchakarma with bare minimum or no belongings and attendants. Patients may be served with 'Ayush kwath tea' [11] after completion of panchakarma therapy. Latest COVID-19 RT-PCR testing (one week before the therapy) should be mandatory for the patient for whom panchakarma is planned. Make sure that the patient is negative before initiation of the therapy. It is advisable to avoid the therapies which involve upper part of the body such as vamana karma, nasya karma, karna poorana etc. However, if physician feels it is necessary then, N95 mask, face shield, disposable gowns, PPE gloves are necessary to be worn by the physician and staff involved in the process. Procedure-wise standard operating practices released by Ministry of AYUSH in the month of January 2021 should be followed during the pandemic while perfoming panchakarma [12] . Instead of going for classical panchakarma during the pandemic, it may be advisable to go for 'sadyo karma' such as sadyovamana, sadyovirechana, matravasti etc after assessing the risk-benefit ratio. It is advisable to use single-use disposable items for the therapies. While planning and administering panchakarma therapy, it is wise to remember the case definition of a contact is "any person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a probable or confirmed case: i. Face-to-face contact with a probable or confirmed case within 1 month and for more than 15 min; ii. Direct physical contact with a probable or confirmed case and iii. Direct care for a patient with probable or confirmed COVID-19 disease without using proper PPE [13] . It is more sensible to handle one case at one time. 8. Panchakarma apashisht prabandhan (waste management) Wastes generated out of panchakarma procedures such as oils, liquids, cotton, hand-gloves, mask, loin clothes, disposable undergarments, empty medicine containers, bottles etc. should be properly disposed as per the latest guidelines and amendments of biomedical waste management rules [14] . The general guidelines which may be employed during panchakarma practice are: before touching a patient, before any clean or aseptic procedure, after exposure to body fluid, after touching a patient, and after touching a patient's surroundings [19] . Staff must be trained by the physician for the hand-washing techniques recommended by WHO [20] . 6. 'The 7 Musts' for safer workplaces viz., wearing reusable face cover, maintaining physical distance, practicing hand hygiene and cleaning surfaces, avoiding spitting in the open, avoiding mass gatherings, being empathetic and self monitoring your health should be be followed [21] . 7. If every staff of the panchakarma hospital/centre including doctor are found negative on COVID-19 testing, you may display a board at the entry point as "COVID-19 safe zone". If possible repeat the testing every week. 8. Any directions from Government of India or local authorities regarding COVID-19 pandemic which may directly or indirectly influence the panchakarma practice should be complied with. 9. These guidelines may be followed till the pandemic persists. While panchakarma is important to cleanse and eliminate disease-causing toxic elements from the body, it is important to follow safety guidelines while performing the same. The abovementioned guidelines may be adopted by panchakarma hospitals/ centres to prevent COVID-19 infection among the patients and HCWs amid the ongoing pandemic. None. Ayurveda and the battle against chronic disease: an opportunity for Ayurveda to go mainstream? New Delhi: Central council for research in Ayurveda and Siddha Lockdown 4.0: 50 quotes from India's battle against COVID-19 PM addresses nation on combating COVID-19 Frequently asked questions (FAQs) about sodium hypochlorite solution(SH) Guidelines for using sodium hypochlorite as a disinfectant for biological waste Microbial growth inhibition by aparajitha dhooma choornam Prolonged presence of SARS-CoV-2 viral RNA in faecal samples Consent in the time of COVID-19 Ayush health promotion product' for commercial manufacturing by Ayurveda, Siddha and Unani drug manufacturersreg. bearing F Guidelines for safe Ayurveda Panchakarma practice in COVID-19 pandemic situation Global surveillance for COVID-19 caused by human infection with COVID-19 virus. Interim guidance 20 AYUSH reiterates immunity boosting measures for self-care during COVID 19 crises WHO guidelines on hand hygiene in health care: first global patient safety challenge e clean care is safer care. 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