key: cord-1039644-tamrvya3 authors: Dinesh, K.S.; Nazeema, P.K.; Archana, Madhavi; Jayakrishnan, K.; Santhi Krishna, A.S.; Swapna, Chitra S.; Sujitha, V.K.; Anju, Sathian; Girish, Babu M.; Geethu, Balakrishnan; Krishnendu, C. title: Application Of A Non-Linear Multi-Model Ayurveda Intervention In Elderly COVID-19 Patients- A Retrospective Case Series date: 2021-07-02 journal: J Ayurveda Integr Med DOI: 10.1016/j.jaim.2021.06.016 sha: fb8332404eba505fa55fe3904732457478374e20 doc_id: 1039644 cord_uid: tamrvya3 BACKGROUND AND AIM: With over 155 million infections, nearly 32 lakh deaths, and an economic toll accounting to trillions, the COVID-19 pandemic is ravaging the world. The mainstream medical system is being handicapped with the challenge of patient management with no proven treatment at one end and the use of vaccine at the other with prevailing ambiguity in developing herd immunity and safety concerns of mass vaccinations amidst pandemic. Though vaccination is the only hope, fool proof evidences are absent on its efficacy. Also, adults of above 65 are of greater risk in terms of complications and death. China has already documented the use of traditional Chinese medicine against the pandemic with national participation rate of 90%. In this regard, the use of complementary and alternative medicine (CAM) against COVID-19 is relevant, especially in a country like India where it is widely practised as Ayurveda. EXPERIMENTAL PROCEDURE: The current report is a retrospective case series of 64 Non-Resident Indians (NRIs) above the age of 60 years tested positive through Reverse Transcription-Polymerase Chain Reaction (RT-PCR) through a Non-Linear multi-modal Ayurveda Intervention (NLMAI) for 21 days consulted through online media. The NLMAI is a combination of herbal and herbo-mineral drug interventions, lifestyle modifications, and psychological support done in 2 phases. RESULTS AND CONCLUSIONS: The management revealed a mean duration of symptoms assessed through survival function of 11 symptoms of COVID-19 as 0.577 days [SE=0.39] with a CI 95% [lower bound=0.500, upper bound 0.653] which was considerably low when compared to global statistics. Moreover, none of the cases advanced to complications or death. The holistic, non-linear, multi-modal approach of Ayurveda may be used to counter the gravity of the COVID-19 pandemic through easy symptomatic recovery, co-morbidity managements and deaths. The Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) causing the Corona Virus Disease (COVID- 19) was first identified in Wuhan, Hubei province of Peoples Republic of China.With over 155 million infections, nearly 32 lakh deaths, and an economic toll accounting to trillions, the COVID-19 pandemic is ravaging the world. [1] The global health workforce fighting against COVID-19 and other infirmities is limited to 4.45 doctors, nurses and midwives per 1000 population indicating a low health worker density. [2] India also accounts for a low health worker density (2.09 health workers per 1000 population) of which 22.8% are AYUSH (Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy) practitioners [3] facilitating the propagation of these systems of medicine in the society especially in Kerala, a state of India. Furthermore, Kerala gained global reputation, in containing the exponential rise of COVID-19 cases through rigorous containment strategies some months back. But however, the current test positivity rate has shoot past 25% on average but with a minimal fatality rate of 0.4%. [4] The Non-Residential Indians (NRI's) of severely infected countries of the Middle East, with limited access to health services due to national priority concerns of host nations and economic stringencies, sought health care measures of traditional medicinal system of Ayurveda. The conventional medical system had the challenge of patient management with no proven treatment for COVID-19 was a rising public concern. The current report is a retrospective case series of 64 Non-Resident Indians (NRIs) above the age of 60 tested positive for COVID-19 sorted treatment due to apprehension towards bio-medical science and affinity towards indigenous systems, managed through the Non-Linear multi -modal Ayurveda Intervention (NLMAI) for 21 days. J o u r n a l P r e -p r o o f The report includes a multicentered retrospective case series of 64 NRI patients above the age of 60 among 300 COVID-19 patients from 9 Middle East nations, who voluntarily sought Ayurveda mode of treatment for between the period 23 rd of March 2020 and the 26 th of June 2020 through various online media. The demographic, domiciliary, clinical data and exposure history were recorded at the time of consultation. The major clinical presentations were fever, cough, dyspnea, headache, fatigue, myalgia, dizziness, nasal congestion, rhinorrhea and abnormal digestion. Along with that, co-morbidities were also noted. Assessed co-morbidities were obesity, hypertension, Diabetes mellitus, cardiovascular disease and COPD. The cases were reluctant to take any sort of Conventional antiviral or antibiotic therapies, rather sought management through Ayurveda at its preliminary stage following diagnosis. The patients were categorized into two groups according to the Ayurveda epistemological approach. The reported cases were 64 elder citizens above the age of 60 with a mean age of 66.4. More males (70.3%) enrolled for the treatment compared to females (29.7%). On tracing the domiciliary status, majority of the identified cases underwent room isolation (95.3%) in their own houses and the rest were isolated in hotels. The subjects reported positive exposure from workplace (50%) and through domiciliary close contacts (50%), whereas no one reported exposure due to international travel. (Table 1 ). The diagnosed co-morbidities are given in table 2 4. Timeline: (Figure 1) The included cases were diagnosed for COVID-19 using the Reverse Transcription-Polymerase Chain Reaction (RT-PCR) tests according to the guidelines on treatment and J o u r n a l P r e -p r o o f prevention laid down by the health ministries of the respective countries and previously diagnosed with co-morbidities. All the diagnosed cases were under isolation and followed Ayurveda interventions as per their personal choice. The clinical symptoms of the patients were recorded by the consultant doctor of Ayurveda, analyzed and periodic follow up was made through online consultation. An Ayurveda mode of diagnosis is also parallelly done for the accurate assessment and delivery of therapeutics as it provides a personalized and preventive health care. [5] On the ground of the epistemological foundation of Ayurveda, the patients were assigned into two intervention groups (Groups A&B) 1 considering the presenting symptom complex in accordance with the predominant dosha of the associated symptoms. [The patho-physiological background for clinical assessment and therapeutics]. [6] (Table. 3) The main aim of interventions was to manage the symptoms of COVID-19 (Phase-1), reduce the possible complications due to co-morbidities in elderly and subsequently improve the immunity of the convalescing patients (Phase-2). The interventions were of nonlinear, dynamic and complex in nature. [7] This includes administration of polyherbal or herbo-mineral compounds (as per the Ayurveda Pharmacopeia of India) which are commonly used for jwara, swasa and kasa (fever and respiratory ailments), lifestyle guidelines and psychological support. It demands individual customization justifying Ayurveda epistemology and availability of the drugs in respective nations. [5] This approach was collectively termed as Non-Linear Multi-modal Ayurveda Intervention (NLMAI). However, no Ayurveda medications were prescribed for comorbidities and the concomitant medications were advised to be continued for the same. • Disciplined observance of routines like sleep-wake cycle, toileting, exercising, bathing and dining for maintaining a healthy biological clock. • Luke warm water for shower (contraindicated during fever). • Steam inhalation with leaves of basil (Ocimum sanctum) daily. • Strict observance of self-isolation, universal masking and handwashing as part of mitigation measures. • Avoid exposure to anything that cause mental stress (sensational news, social media posts and the like) • Observance of healthy food and eating practices as per Ayurveda • Follow strict vegetarian diet. • Intake of Herbal drinks/ decoctions processed with O. sanctum leaves and Zingiber officinale tubers -twice a day. • Avoid intake of too much sour, salty and spicy food items. • Light diet with plenty of liquids preferably rice gruel. • Avoid refrigerated foods, aerated drinks, junk foods, picky eating and confectionaries. The prescriptions were generated and sent after the online consultation. The patients were asked to collect the medicines according to the legal norms of the country they reside. The contact details of voluntary services, human welfare organizations and proximate Ayurveda practitioners were shared to them who could help in dispensing the medicines. The patients were requested to invariably report to the doctors through available online/telephonic media at regular intervals (at least once in 7 days from the initial consultation) or at any time in case of emergencies. The outcomes were recorded for both J o u r n a l P r e -p r o o f phase-1 and phase-2 treatments based on patient self-reporting and clinician interrogation. Even though the rejuvenative (Rasayana) drugs were advised in phase-2 treatment, the current assessment was focused only to phase-1 treatment and co-morbidities. The Patient adherence and compliance to the interventions was ensured through 'telephone-based pill count method' and periodic phone calls. The adherence of lifestyle guidelines was ensured through online family interviews. The Psychological support to the elderly was also ensured adopting the guidelines of government supported program "Koode" organized by the Malappuram district governance of Kerala state. The data collected during online consultations and follow-up were stored in excel sheets. Consent from each patient was procured verbally during the consultation. The patients were assessed based on commonly reported clinical symptoms of COVID-19 as per authentic online database and were subjected to assessment. Among them, sore throat (100%), fever (92.2%), anosmia (28.13%), nasal congestion (20.31%), cough (18.75%), Rhinorrhea (18.75%), myalgia (18.75%) and fatigue (12.5%) and were most prevalent, followed by, Diarrhea (6.25%), Abnormal digestion (4.68%) and Dizziness (3.13%). (Table 4 ) For the ease of therapeutic intervention, the patients were categorized into two groups based on the associated symptoms. Hyperemia due to inflammation of throat, mouth and nose, skin rashes, burning sensations and diarrhea were included in pitta category and Rhinitis, chills, feverishness, heaviness and loss of appetite were categorized under kapha. The year 2020 has engraved its signature in the history of mankind as it led to a situation of human isolation, fear and stagnation not known for a century. The COVID-19 pandemic swept through continents creating havocs to mankind in almost all countries irrespective of developments in technology and medicine. India with its high population density, is hit badly by the pandemic wave. This has forewarned the heterogenous medical structure of India comprising both conventional and the AYUSH systems. In the initial phases of the infection, the health ministry endorsed conventional system for the treatment of COVID-19 and the AYUSH systems to be used for preventive strategies. Table 6 . Similarly, the time duration from virus positivity to negativity was 5. The median duration of fever and associated symptoms of COVID-19 was 10 days (CI 95%; 8-11 days). [18] Here, none of the affected individuals received any hospital-based interventions, Still the average time for clinical improvement of fever and associated symptoms through NLMAI is found to be significant. (Table-5 In addition, the reported co-morbidities were obesity (18.75%), hypertension (46.87%), diabetes mellitus (43.75%), cardiovascular disease (28.15%) and COPD (7.81%). COPD, Cognitive impairment, diabetes, hypertension, and stroke are significant contributions of health care utilization and hospital admissions among covid 19 patients. [19] . Increased risk of mortality with advanced age were also reported [20] , [21] All available evidence suggest that presence of co-morbidities is associated with poor outcome of covid 19 patients [22] , [23] However, in the current study, no complications were reported in any of the affected cases during their course of illness and follow-up. Individuals with age <65 account for 4.5-11.2% of all COVID-19 deaths in European countries and Canada, it is 8.3-22.7% in the US locations, and were the majority in India and Mexico. People in age group <65 years old have lower risks of COVID-19 death even in pandemic epicenters. Analytics revealed that, In India COVID-19 mortalities of age group <65 years were 49.5% of the total deaths and risk of death in people with age <60 is 5 per million. [24] In the present case report, not even a single fatality due to COVID-19 were reported during the NLMAI and follow-up period, which can be speculated as a good outcome. 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