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Vol 24, No. 04, April 2020   |   Issue PDF view/purchase
FEATURES
Epidemiology of COVID-19 and Perspectives from Chinese Medicine

The current understanding

COVID-19, caused by SARS-CoV-2, has taken 4, 613 lives and infected more than 125, 048 people globally as of 12 March 2020.a Phylogenetic analysis showed that SAR-CoV-2 may have appeared since late November and spread through human-to-human transmission via contact or droplet.1, 2 Aerosol and oral-faecal routes are also gaining increasing attention and evidence. Recently, virology study identified asymptomatic carriers with comparable viral load with other patients and asymptomatic transmission is widely suspected.3

COVID-19 patients could present with mild flu-like symptoms on the first 1-2 days and 56.2 percent were afebrile (defined as armpit temperature below 37.5oC on admission).4 After 3-6 days of exposure, majority of patients will develop fever (around 90 percent), fatigue, cough and shortness of breath. Minority of them would also present with myalgia or arthralgia and gastrointestinal symptoms.4 Less than 20 percent of cases would progress to severe and even critical cases; currently estimated mortality is 1-2 percent.4, 5 Progression is associated with age and underlying comorbidities, especially hypertension and diabetes. Currently, there is no established regimens or vaccines for COVID-19 that are supported by well-designed clinical trials.1

The understanding from the Chinese Medicine perspective

Chinese medicine is ancient yet innovative that it uses symptom-based diagnosis to stratify patients and formulate treatment, an approach which different disciplines of conventional medicine started to explore.6 The focus of Chinese medicine is not on the virus, but on the overall clinical presentation after the infection. Epidemic infectious diseases are called pestilence in Chinese medicine theory and each pestilence has its characteristics. On top of respiratory tract infection associated presentations, patients were commonly reported to co-present with myalgia or arthralgia, gastrointestinal symptoms, thick greasy fur on tongue and slippery pulse. These features are related to dampness and spleen.7

Another feature of Chinese medicine is the consideration of weather and the underlying condition of subjects in assessing the pathogenesis and predicting the individual disease progression. Wuhan experienced a warm winter during early to mid-November 2019 (over 20oC daytime) followed by a sudden temperature drop on 24 November from 18sup>oC to 4sup>oC and rise in humidity from 63 percent to 89 percent on 25 November. The huge drop in temperature and increase in humidity increased the susceptibility to exogenous cold-dampness which is compatible to the presentation of greasy tongue fur among the reported cases. The core pathogenesis of COVID-19 is therefore dampness pestilence caused by external cold-dampness distressing lung and spleen.8 The transformation to heat or cold would depend on the individual patients’ level of endogenous heat.

Treatment

Chinese medicine treatment is personalized. However, as each pestilence has a unique pattern, China’s national guideline (Guideline) on COVID-19 associated pneumonia could be considered as a reference.

The 6th version of the Guideline was released on 18 February 2020.9 Chinese medicine regimens were proposed for both medical observation period and treatment period. During observation period, the recommended formulation for patients presented with fatigue and gastrointestinal disorder was huo-xiang-zheng-qi capsule and that for patients presented with fatigue and fever are jin-hua-qing-gan granules, lian-hua-qing-wen capsule or shu-feng-jie-du capsule. Patients in the treatment period are further stratified into four manifestations including mild (cold-dampness distressing lung or dampness-heat accumulation in lung), intermediate (endemic toxin distressing lung or cold-dampness blocking lung), severe (pestilence toxin retention in lung or intense heat in qi and ying systems) and critical (internal obstruction and external collapse) with corresponding classical presentations and recommended formulations. Over 85 percent of confirmed cases used Chinese medicine in China.10, 11

Evidence

Numerous retrospective cohorts,12-14 case-series,15-19 and case studies20, 21 on Chinese medicine intervention for the management of COVID-19 were reported since the outbreak. The regimens used involved semi-individualised Chinese medicine based on the Guideline and propriety Chinese medicines (Lian-hua-qing-wen granules, Qing-fei-pai-du decoction and Toujiequwen granules).

Overall, the use of add-on Chinese medicine (both semi-individualised and proprietary) was reported to have significant effect in symptomatic improvement, reducing fever duration, reverting radiological changes and reducing hospital stay.12-14 Nevertheless, these results should be interpreted cautiously as there was a general inadequacy in methodology description and quality, which is not uncommon in an outbreak clinical setting. In silico studies showed that many of the herbs involved (ma-huang, chai-hu, huang-qi, sang-ye, jin-yin-hua, lian-qiao, zhe-bei-mu, gan-cao) have strong affinity to ACE2 receptor22-25 and may act through regulating key immunological pathways and TNF signalling pathway.26

SARS experience

Chinese medicine was heavily involved in SARS treatment in China as well. In a report released by World Health Organisation in 2004 on an international meeting with experts from six countries, add-on Chinese medicine was suggested to have possible benefits of “alleviation of fatigue, shortness of breath and other clinical symptoms; facilitation of lung inflammation absorption; reduction of the risk of oxygen desaturation and the stabilization of abnormal fluctuation of oxygen saturation in the blood; reduction in the dosage of glucocorticoid and antiviral agents (and therefore in their associated side-effects) and reduction of cost (treatment with TCM alone costs less than treatment with Western medicine alone)”.

In Hong Kong, Chinese medicine was used as a preventive measure during SARS. Among the health care workers (n=37,174), Chinese medicine users (n=1,063) were reported to have a better quality of life and increase in CD4/CD8 T-lymphocytes with no SARS infection after taking the preventive formulation (sang-ye, ju-hua, xing-ren, lian-qiao, bao-he, jie-geng, gan-cao, lu-gen, huang-qi, fang-feng, da-qing-ye and huang-qin) for 2 weeks.27, 28 A recent meta-analysis showed similar effect of Chinese medicine on lowering infection rate of H1N1 (relative risk: 0.36, 95%CI: 0.24 to 0.52).29

Conclusion

The two SARS-CoVs are frequently compared by the general public. It is true that the two viruses have similarities, but their clinical presentation is different. We are fortunate that the mortality of COVID-19 appears not as devastating as SARS. However, a previous study showed that host mortality is inversely correlated with transmissibility.30 International experts remained cautious that COVID-19 may last for a long period and has been declared a global pandemic by the World Health Organization on 11 March 2020.b At present, while we are waiting for more evidence on vaccines and pharmacological treatments from conventional medicine, we should not forget that Chinese medicine is an option that we could consider.

Footnotes

  1. Based on World Health Organization Coronavirus disease 2019 (COVID-19) Situation Report – 52, 12 March 2020
  2. Based on World Health Organization Director-General’s opening remarks at the media briefing on COVID-19, 11 March 2020

References

  1. Heymann, D.L. and N. Shindo, COVID-19: what is next for public health? The Lancet, 2020. 395(10224): p. 542-545.
  2. GISAID Initiative, Genomic epidemiology of BetaCoV 2019-2020. 2020.
  3. Zou, L., et al., SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med, 2020.
  4. Guan, W.J., et al., Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med, 2020.
  5. Wang, D., et al., Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA, 2020.
  6. Sood, R., G.R. Law, and A.C. Ford, Diagnosis of IBS: symptoms, symptom-based criteria, biomarkers or 'psychomarkers'? Nat Rev Gastroenterol Hepatol, 2014. 11(11): p. 683-91.
  7. Wang, Y., et al., TCM clinical features and syndrome differentiation of new coronavirus (2019-nCoV) pneumonia. Journal of Traditional Chinese Medicine, 2020. 61(4).
  8. Tong, X., et al., Discussion on traditional Chinese medicine prevention and treatment strategies of new coronavirus pneumonia (COVID-19) from the perspective of "Cold and Dampness Epidemic". Journal of Traditional Chinese Medicine, 2020.
  9. National Health Comission and National Administration of Traditional Chinese Medicine, Diagnosis and treatment of pneumonia caused by new coronavirus (trial version 6). 2020, National Health Comission, National Administration of Traditional Chinese Medicine: Beijing.
  10. Le, W. and J. Liang, The Chinese medicine system sent 2,220 people to support Hubei. 2020, Xinhua Net.
  11. The State Council The People's Republic of China, Latest developments in epidemic control 21 February 2020. 2020, The State Council The People's Republic of China.
  12. Yao, K., et al., Retrospective clinical analysis on treatment of novel coronavirus-infected pneumonia with traditional Chinese medicine Lianhua Qingwen. Chinese Journal of Experimental Traditional Medical Formulae 2020.
  13. Lu, R., W. Wang, and X. Li, Clinical observation on 63 cases of suspected cases of new coronavirus pneumonia treated by Chinese medicine Lianhua Qingwen. Journal of Traditional Chinese Medicine, 2020.
  14. Xia, W., et al., Clinical study on 34 cases of new coronavirus pneumonia treated with integrated traditional Chinese and western medicine. Journal of Traditional Chinese Medicine, 2020.
  15. Dai, M., et al., Preliminary analysis of clinical manifestations of Lingnan new coronavirus pneumonia. Tianjin Journal of Traditional Chinese Medicine, 2020.
  16. 16Guangdong Medical Products Administration, Notice on the clinical use of Tongjie Quwen Granules (formerly known as "pneumonia No. 1"). 2020, Guangdong Medical Products Administration: Guangdong.
  17. National Administration of Traditional Chinese Medicine, Progress in screening of effective prescriptions of traditional Chinese medicine. 2020, National Administration of Traditional Chinese Medicine: Beijing.
  18. Cheng, D. and Y. Li, Clinical effectiveness and case analysis in 54 NCP patients treated with Lanhuaqingwen granules. World Chinese Medicine, 2020.
  19. Yong, W., et al., Analysis of 4 cases of corona virus disease-19 treated by integrated traditional Chinese and western medicine in Gansu. Shanghai Journal of Traditional Chinese Medicine, 2020.
  20. Hu, M., et al., A case of severe new coronavirus pneumonia treated by integrated traditional Chinese and western medicine. Chinese Journal of Integrated Traditional and Western Medicine, 2020.
  21. Sun, Z., et al., Discussion on new coronavirus infected pneumonia based on staging of differentiation and treatment. Journal of Shaanxi University of Chinese Medicine 2020.
  22. Niu, M., et al., Rapid establishment of traditional Chinese medicine prevention and treatment for the novel coronavirus pneumonia based on clinical experience and molecular docking. China Journal of Chinese Materia Medica, 2020.
  23. Ma, J., et al., Study on screening Chinese traditional medicine against SARS-CoV-2 based on Mpro and PLP. China Journal of Chinese Materia Medica, 2020.
  24. Li, J., et al., Screening of active components from traditional Chinese medicine against novel coronavirus based on literature mining and molecular docking. Chinese Traditional and Herbal Drugs, 2020.
  25. Chen, H. and Q. Du, Potential natural compounds for preventing 2019-nCoV infection. Preprints, 2020. 2020010358.
  26. Zhao, J., et al., Investigating the mechanism of Qing-Fei-Pai-Du-Tang for the treatment of novel coronavirus pneumonia by network pharmacology. Chinese Traditional and Herbal Drugs, 2020.
  27. World Health Organisation, Clinical trials on treatment using a combination of Traditional Chinese medicine and Western medicine. 2004, World Health Organisation: Geneva. p. 1-194.
  28. Leung, P.C., The efficacy of Chinese medicine for SARS: a review of Chinese publications after the crisis. Am J Chin Med, 2007. 35(4): p. 575-81.
  29. 29Luo, H., et al., Can Chinese medicine be used for prevention of corona virus disease 2019 (COVID-19)? A review of historical classics, research evidence and current prevention programs. Chin J Integr Med, 2020.
  30. Geoghegan, J.L., et al., Virological factors that increase the transmissibility of emerging human viruses. Proc Natl Acad Sci, 2016. 113(15): p. 4170-5.

About the Authors

Vivian Taam Wong, FFPH, FRCP, FRCOG, FHKAM, is Hon Professor in the School of Chinese Medicine, HKU; Hon President of HK Association for Integration of Chinese-Western Medicine and Executive Board Member of Chinese Association for Integrative Medicine. She documented the materno-fetal transmission of hepatitis B and pioneered the use of immunoglobulin and vaccine to prevent perinatal transmission 30+ years ago. She was Public Health Specialist for The World Bank and Consultant for WHO. She has been Chief Executive of Queen Mary Hospital, the teaching hospital of HKU and of the Hospital Authority, HK where she coordinated the SARS response in 2003.

Chan Kam Wa (Chris), BCM, MSPH, MD, PHD, received training on clinical Chinese medicine, biomedical science and public health from The Hong Kong Baptist University, Guangzhou University of Chinese Medicine, The University of Hong Kong and London School of Hygiene & Tropical Medicine. He served for World Health Organisation on research consultancy, Hospital Authority on medical administration, Tung Wah Group of Hospitals on clinical medicine, KPMG Advisory on healthcare policy consultancy before his academic engagement at the Department of Medicine, The University of Hong Kong/Queen Mary Hospital. His research focus is on traditional theory, qualitative, mechanistic, data analytics and clinical studies on integrative Chinese-western interventions for various diseases, especially for diabetes and diabetic kidney disease.

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