Integrative Medicine Treatment in Times of Pandemic Coronavirus Disease?

Coronavirus disease (COVID-19) has expanded around the world, resulting in a pandemic with high morbidity and mortality. To date, no specific treatment or vaccine is available to treat or prevent this sudden and potentially deadly disease. Economic restructuring brings opportunities and challenges to integrative medicine treatment. In such complex situations, integrative medicine treatments are to be provided cautiously, and the shift from in-person visits to remote medical services might play an important role in how such services are delivered.

tory tract of patients and potentially resulting in critical pneumonia was originally reported in Wuhan, Hubei province, China in December 2019, and named as coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) officially on February 11, 2020. 1 It is another pathogenic viral infection caused by a novel coronavirus, labeled as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmitted across the animal-human interface. Studies have indicated that its pathogens spread through populations by transmission through respiratory droplets, contact, and natural aerosols. 2 Fever, tiredness, and dry cough are the most common signs and symptoms of patients with COVID-19, 25.9% of them will develop serious pneumonia requiring intensive care unit (ICU) admission and 20.1% may develop acute respiratory distress syndrome. 3 Due to alarming levels of spread, and severity, the coronavirus outbreak has been declared as a global pandemic by the WHO on March 11, 2020. 4 As of June 3, 2020, the virus has spread to 216 countries, areas, and territories, and 6,272,098 confirmed cases and 379,044 confirmed deaths have been reported to the WHO. 5 Patients with COVID-19 have been found to have higher transmissibility and greater pandemic risk than SARS-CoV. 6 Given previous experience of management of Middle East Respiratory Syndrome Coronavirus and SARS-CoV, the WHO released infection control interventions recommendations to decrease the general risk of pathogen infection or transmission including wearing facial masks, regular hand cleaning, 6 feet social distance, and stay home policy. Furthermore, health care facilities should improve infection prevention and control practices in clinics and hospitals. 3 At present, except for supportive care, for example, oxygen therapy, mechanical ventilation, and fluid management, there are no clear or convincing evidence-based interventions known to be of benefit for COVID-19 patients. 7 Remdesivir is only mentioned as 1 investigational therapy through either compassionate drug use or ongoing clinical trial. 8 Currently, diagnosis and treatment protocols are developed based on patients from China and other countries around the world to better define this pandemic. Chinese National Health Commission & State Administration of Traditional Chinese Medicine has published the seventhversion Guideline of ''The Chinese Clinical Guidance for COVID-19 Pneumonia Diagnosis and Treatment,'' which is widely used in clinical practice in China. 9 The U.S. Centers for Disease Control and Prevention (CDC) published Interim Guidance on Management of COVID-19 to implement aggressive measures to stop the virus spreading in the United States. 10 Since at the present time there is no vaccine available, the best way to prevent the spread of COVID-19 infection is to avoid being exposed to the virus. Sufficient medical quarantine to reduce exposure and limit transmission to others is a critical first step of COVID-19 prevention and control. Suspected patients need to be quarantined, confirmed patients are transferred to the same general ward, and severe cases should be admitted to the ICU as soon as possible.
Increasing social isolation and loneliness due to widespread outbreak of COVID-19 is inevitable strongly associated with public panic and adverse mental health consequences of psychologic distress and symptoms of mental illness such as anxiety, sadness, stress, depression, selfharm, and even suicide attempts, especially among vulnerable populations and health care workers. 11 Most COVID-19 patients initially suffer from fever, cough, dyspnea, anxiety, stress, and other symptoms including musculoskeletal pain, nausea, and diarrhea for which patients may first seek help using integrative medicine treatments. These can include diverse therapies such as herbal therapy, acupuncture, massage, mind-body practice, and others. Many of these modalities require face-to-face contact and, therefore, the outbreak of COVID-19 has also posed a great challenge to the clinical practice of integrative medicine therapies. 12

HERBAL THERAPY
Previous studies have shown that Chinese herbal remedy might play a crucial role in the prevention and treatment of epidemic diseases such as SARS-CoV and influenza A virus subtype H1N1 (A/H1N1) with a higher recovery rate and lower medical cost in China. 13,14 Fourteen patients with influenza A/H1N1 flu were reportedly cured with integrative treatment of Chinese herbal remedies in Beijing Ditan Hospital and Chengdu Infectious Diseases Hospital, China. 13 Approximately 40%-60% of hospitalized SARS patients received an integrated approach of modern and Chinese herbs. Positive effects of Chinese herbal therapy as an adjuvant showed improvement of fever, chest infection, less steroids consumption, and immunologic boosters. 14 Chinese National Health Commission & State Administration of Traditional Chinese Medicine released guidelines regarding systemic treatment with Chinese herbal remedies for COVID-19 patients in different stages. For example, in the seventh editions of Guidelines of Traditional Chinese Medicine treatment, Chinese herbal remedy Huoxiang Zhengqi capsule is advised for fatigue and gastrointestinal discomfort; Jinhua Qinggan granules, Shufeng Jiedu capsules, Lianhua Qingwen capsules, and Fangfeng Tongsheng pills for fatigue and fever of suspected patients; lung cleansing and detoxifying decoction and other herbal de-coctions are recommended to confirmed cases; Xiyanping and other Chinese medicine injections are applied on severe and critical cases; and it seems that Chinese herbs may have positive effects on major symptoms such as fever, cough, and promote recovery. Further laboratory research and clinical trials with regard to the efficacy and safety of wide application of these herbal remedies on COVID-19 patients are urgently needed [15][16][17] (Table 1).

MIND-BODY THERAPIES
Psychologic factors are an essential component in the success of public health strategies used for the management of epidemics and pandemics. Studies indicate that subsyndromal psychiatric disorders such as anxiety, distress, and fear are a common response to the COVID-19 pandemic, particularly in the unemployed or vulnerable population, which potentially impact on the ongoing efforts of public communication, hygiene practices, social distancing, vaccination, and antiviral therapy. People with mental anxiety may engage in a variety of maladaptive safety behaviors, which includes compulsive hand washing, panic buying, and social isolation. 18,19 Mind-body therapies could guide patients to nonpharmacologic approaches to manage their emotions and discomfort. Being simple and useful home-based workouts, Ayurveda, Yoga, Tai chi, or meditation have already played a major role in the prevention and postrecovery management of COVID-19. 20,21 Remote instructions could be offered by health care providers even under a stay-at-home order. And the efficacy and safety of these modalities used in the treatment of emerging coronavirus infections will need to be evaluated in future studies.

Acupuncture
China Association of Acupuncture-Moxibustion published ''Guidance for acupuncture and moxibustion interventions on COVID-19 (Second edition),'' which highlights the beneficial effects of Traditional Chinese Medicine interventions including acupuncture and other related therapies such as moxibustion, Tuina, traditional physical exercise, and foot bath fumigation. Acupuncture with different acupoints combination for suspected, confirmed, and recovery of COVID-19 patients is recommended separately. 22 Acupuncture-related therapies such as bloodletting of auricular and hand points for confirmed patients with repeated fever and moxibustion exerted for 10 to 15 minutes at each point for patients in recovery stage as well as other interventions such as scraping, point injection, Tuina and others are recommended. Self-interventions are advised to apply at home under the instruction of a physician. 23 An exploratory study focused on acupuncture treatment in COVID-19 patients reported that Dr. Zhou, a critical care medical expert
One dose per day, 400 mL after decocting, and equally divide into 2 and taken in the morning and evening.
-Qi and Yin deficiency syndrome Fatigue, shortness of breath, dry mouth, thirst, heart palpitation, profuse sweating, poor appetite, low-grade fever or no fever, dry cough with little sputum. The tongue is dry tongue with scanty fluid. The pulse is thready or weak and forceless. One dose per day, 400 mL after decocting, and equally divides into 2 and taken in the morning and evening.

Nan Sha Shen
who supported Wuhan Leishenshan hospital, applied acupuncture on COVID-19 confirmed patients for shortness of breath, cough, dizziness, insomnia, restlessness, palpitations, diarrhea, and vomiting. In addition, Dr. Liu, a Traditional Chinese Medicine expert who also treated COVID-19infected patients in Wuhan with acupuncture, summarized that acupuncture could have positive effects in improving chest congestion, shortness of breath, abdominal discomfort, itchy throat, cough, dizziness, pain, and sweating. 24 Acupuncture manipulated by licensed acupuncturists involves the insertion of metal needles and heat or cold stimulation into the precise acupoints on human bodies. Acupuncturists are at high risk of getting infected when they closely examine the patient and do acupuncture manipulations; personal protective equipment (PPE) is needed if they operate these treatments; however, a critical shortage of PPE has already posed a major risk of COVID-19 being spread 25 ; and protecting the medical workforce is a critical challenge. During these pandemic outbreaks, severe health care provider infections and deaths have already been reported, making the staff vulnerable to significant psychosocial stress. 26,27 Moreover, it is very inconvenient to do the manipulations wearing triple layer protective gloves either. During the treatment, if medical provider's hand hygiene, PPE, or other infection prevention and control measures are not in place, they are at great risk of infection and possibly become the virus carriers to the other patients, family members, and the community.
Possibly due to the mentioned limitations, during an acute COVID-19 outbreak, acupuncture-related in-person therapies should be cautiously performed since the high risk of possible virus spreading is much greater than any possible benefit. Possibly due to the mentioned limitations, related therapies, acupuncture-related therapies, which require inperson visits were not included in the diagnosis and treatment protocols as one of the first-line treatment options for COVID-19 published either by Chinese National Health Commission & State Administration of Traditional Chinese Medicine or by the U.S. CDC.
Timely treatment and prevention of COVID-19 are paramount for public health and the well-being, whereas the economic impact on the society is another issue we should think about the fact that economic recession itself has a negative effect on health. To prevent the pandemic spread, expand health capacity to care, and to conserve adequate medical staff and supplies for COVID-19 patients, especially PPE, nonemergent, elective medical services, and treatment are limited, many economic policy tools have also been used for a response to the support of social distancing and hygiene. Therefore, in the United States, integrative medicine as a supplementary of conventional medicine is suspended or shut down in response to CDC guidelines, which resulted in an urgent shift from the traditional inperson service model to remote health care.
The continuing COVID-19 pandemic almost affects economic activities in every country on this planet. The global economy is in the deepest contraction since the great depression, a reduction in economic activity reduces the circulation of money, which results in a heavy hit to the middle-class people, salaried people, organized sector, etc. 28 Unemployment could influence both the physical and mental health, which might aggravate the negative consequences of the pandemic in a vicious circle. It is a great challenge to reopen some economies around the world. At present, in some areas with a low, or relatively low and stable incidence of COVID-19, medical facilities have allowed the flexibility to provide care for patients needing nonemergent non-COVID-19 health care.
Economic recovery under COVID-19 is definitely a double-edged sword, by reopening the economy there is a potential risking of a second wave. Economic restructuring brings opportunities and challenges to integrative medicine treatments. In such a complex situation, integrated medicine treatments need to be cautiously provided with the premise of safety. The health care providers should weigh their own risk and comfort level when deciding whether to continue providing in-person integrative medicine services. No inperson visit is risk free, even if both patient and practitioner appear well. To prevent the spread of COVID-19, in-person integrative medicine appointment should be limited to patients with a clear and documentable urgent medical need. Further suggested safety recommendations during this pandemic include: prescreening each patient by phone before the consultation; staggering appointments so that patients do not overlap; adequate disinfection of any surfaces that may have been contacted, removing or recycling any nonessential items which could be a vector for virus transmission in the healthcare setting. With the adoption of telehealth medical care can safely be provided to patients in appropriate situations. The shift from in-person appointments to remote medical services might play a new important role in the future.

CONCLUSION
The global pandemic of COVID-19 has become a public health emergency to the general public and health care providers. Our understanding of this sudden and lethal virus is still very limited. Safe effective antiviral medication and vaccine are still not available, the only thing we can do at this point is aggressively implement appropriate infection prevention and control measures to curb the spread of this virus transmission. Economic restructuring brings opportunities and challenges to integrative medicine treatment. Integrative medicine treatments are to be provided cautiously, and the shift from in-person visits to remote medical services might play a new important role in the coming medical services.