A clinical approach to COVID-19

Akshata Jaiswal1, Swapnil Borage*2, Priyanka Shelotkar3 1Mahatma Gandhi Ayurved college , Hospital and research center, Salod (H), Wardha, Datta Meghe Institute Of Medical Sciences (DU), Wardha, Maharashtra, India. 2Department of Shalakya tantra, Mahatma Gandhi Ayurved college , Hospital and research center, Salod (H), Wardha, Datta Meghe Institute Of Medical Sciences (DU), Wardha, Maharashtra, India. 3Department of Kaumarbhritya, Mahatma Gandhi Ayurved college , Hospital and research center, Salod (H), Wardha, Datta Meghe Institute Of Medical Sciences (DU), Wardha, Maharashtra, India.


INTRODUCTION
Corona Virus disease 2019 (COVID-19) is de ined as an illness caused by a novel Corona Virus which was irst identi ied amid an outbreak of respira-tory illness cases in Wuhan City, China. On January 30th, 2020, the WHO declared the COVID-19 epidemic a global health emergency. On March 11th, 2020, the WHO announced COVID-19 a global pandemic, its irst such designation since reporting H1N1 in luenza a pandemic in 2009. Illness caused by SARS-CoV-2 was recently termed COVID-19 by the WHO, so derived from "Corona Virus disease 2019." All over the world total, 1,521,966 cases of the corona were reported of which 332,310 have recovered with 88,659 deaths. (Global cases by the CSSE, 2020) CoVs are positive-stranded RNA viruses with a crown-like appearance under an electron microscope. SARS-CoV-2 belongs to the beta CoVs category. It has a round/elliptic form. Like other CoVs; it is sensitive to ultraviolet rays and heat. Further-more, these viruses can be effectively inactivated by lipid solvents, including ether (75%), ethanol, and chlorine-containing disinfectant and chloroform. (Cascella et al., 2020).

Therapeutic Procedure
As the world continues to try to control the spread and impact of the Corona Virus disease 2019 , there is an increasing focus on the care and treatment of symptomatic patients who are SARS-CoV-2 positive. There are currently no FDA-approved medications for the treatment or prevention of COVID-19. However, drugs that are approved to treat other diseases may be useful and are presently being used and studied.
The clinical management of COVID 19 includes screening and triage, i.e. early detection of patients, implementation of appropriate IPC measures, collection of samples for investigation, symptomatic treatment, oxygen therapy and monitoring, prevention of complications, adjunctive therapy. Safety and ef icacy for these drugs are not yet established in patients with COVID-19. Patients receiving Hydroxychloroquine, Chloroquine and Azithromycin for FDA-approved uses have reported dif iculty in illing their prescriptions, presumably because the drugs are being used to treat COVID-19.

Screening and Triage
Screen and isolate all patients suspected with COVID 19 at the irst point of contact with any health care system. Consider Covid 19 as possible aetiology of the patients with complaints of acute respiratory illness under certain conditions. Triage patients using standardised triage tools and start irst-line treatment. The presence of viruses in samples is conirmed by RT-PCR, which detects the Corona Virus' RNA. This test is speci ic and is designed to detect the RNA of the SARS-CoV-2 virus. It is used to conirm recent or acute infections.
Detection of antibodies can be used both for diagnosis and population awareness. Antibody tests show how many people have had the disease, including those whose symptoms were minor. An accurate mortality rate of the disease and the level of herd immunity can be determined from the results of this test. (World Health Organization, 2020).

Immediate implementation of IPC [Infection Prevention and Control] measures
It has been adapted from WHO's Infection preven-tion and control, during health care for probable or con irmed cases of Middle East respiratory syndrome Corona Virus (MERS-CoV) infection, based on current knowledge of the situation in China and other countries where cases are identi ied, and experiences with the severe acute respiratory syndrome (SARS)-CoV and MERS-CoV.
1. Initiate IPC at the point of entry of the patient to the hospital. Screening should be done at the irst point of contact at the emergency department or outpatient department/clinics. Suspected COVID-19 patients should be given a mask and directed to a separate area. Keep at least 1 m distance between suspected patients.
2. Standard precautions should always be applied in all areas of health care facilities. Standard precautions include hand hygiene and the use of personal protective equipment (PPE) when in indirect and direct contact with patient's blood, body luids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment. (Contaminated, 2020).
3. In addition to standard precautions, health care workers should do a point-of-care risk assessment at every patient contact to determine whether additional precautions (e.g. droplet, contact, or airborne) are required. (Training, 2020).

Remdesivir
Remdesivir is an investigational intravenous drug with a broad antiviral activity that inhibits viral replication through premature termination of RNA transcription and has in-vitro activity against SARS-CoV-2 and in-vitro and in-vivo action against related beta Corona Viruses. Remdesivir is an investigational antiviral drug being developed by Gilled Sciences for the treatment of Covid-19, a Corona Virus disease, and Ebola virus infection. (Saha et al., 2020).
The drug is currently not approved for any indication globally. The US Food and Drug Administration (FDA) reviewed the investigational new drug (IND) application iled by the company for Remdesivir to treat Covid -19 and granted experimental study the drug in February 2020. The drug is supplied as a stable formulation for intravenous administration during clinical development. Remdesivir inhibited the ability of the Corona Viruses that cause SARS and MERS to infect cells in a laboratory dish. The drug also was effective in treating these Corona Viruses in animals. There was a reduction in the amount of virus in the body, even an improvement in lung disease caused by the virus. (Eastman et al., 2020).
The drug appears to be effective in the laboratory dish, in protecting cells against infection by the COVID virus. Remdesivir was used in the irst case of COVID-19 that occurred in Washington State, in January 2020. The patient was severely ill but survived. Of course, experience in one patient does not prove the drug is effective. (Herper, 2020).

Hydroxychloroquine and Chloroquine
Hydroxychloroquine and Chloroquine are oral prescription drugs that have been used for the treatment of malaria and certain in lammatory conditions.
Hydroxychloroquine and Chloroquine are under investigation in clinical trials for preexposure or post-exposure prophylaxis of SARS-CoV-2 infection, and treatment of patients with mild, moderate, and severe COVID-19. (Ben-Zvi et al., 2012) .
No drug is perfectly safe, but these drugs are quite safe when used for just the several days they might be needed to treat COVID-19. They are also cheap, already available at our local drug stores, and relatively free of side effects. There is strong evidence that both drugs kill the COVID-19 virus in the laboratory dish. The drugs appear to work through two mechanisms. First, they make it harder for the virus to attach itself to the cell, inhibiting the infection from entering the cell and multiplying within it. Second, if the virus does manage to get inside the cell, the drugs kill it before it can reproduce. (Yao et al., 2020).
One report, published in February 2020, claimed that Chloroquine had been used in more than 100 patients in China who had COVID-19. The scientists stated that their results demonstrated that Chloroquine is superior to the control treatment in inhibiting the worsening of pneumonia, improving lung imaging indings, eliminating the virus from the body, and shortening the duration of the disease. (Gao et al., 2020) .

Hyperbaric oxygen therapy
Hyperbaric oxygen therapy (HBOT) treatment is provided to patients as an adjunct to standard therapy for COVID19-positive patients with respiratory distress. All patients before the clinical application of HBOT will be evaluated by the primary care team and hyperbaric physician.
This is a single-centre prospective pilot study to evaluate the safety and ef icacy of hyperbaric oxygen therapy (HBOT) as an emergency investigational device for treating patients with Corona Virus, disease, COVID-19. Patients that meet inclusion cri-teria will be asked to give consent by the hyperbaric physician. They will then be transported from the ED or other unit to the hyperbaric unit maintaining airborne precautions based on the most current hospital protocol. All study personnel will have proper PPE at all times. The patient will then be placed into the mono-place chamber, and when the chamber door is closed, the patient will remove any respiratory ilter/mask that was placed. The patient will receive 90 minutes of hyperbaric oxygen at 2.0 ATA with or without air-breaks per the physician. Upon completion of the treatment, the patient will then return to the medical unit and continue all standard of care. Additional treatments (up to 5) can be given if warranted and agreed upon by the patient and all members of the team caring for the patient. (Chander et al., 1999) .

Convalescent Plasma Therapy
Convalescent Plasma Therapy, plasma from a COVID-19 recovered patient, is transfused into an infected patient. The antibodies present in the plasma of the recovered patient help in neutralising the SARS-CoV-2 virus in the infected patients. CONVALESCENT PLASMA THERAPY plasma from a COVID-19 recovered patient is transfused into an infected patient. The antibodies present in the plasma of the recovered patient help in neutralising the SARS-CoV-2 virus in the infected patient. (Lu et al., 2016) .
Though convalescent plasma has been used for many years, and with varying success, not much is known about how effective it is for treating COVID-19. There have been reports of success from China, but no randomised, controlled studies (the gold standard for research studies) have been done. Experts also don't yet know the best time during the illness to give plasma. (Chen et al., 2020) . On March 24th, the FDA began allowing convalescent plasma to be used in patients with severe or immediately life-threatening COVID-19 infections. This treatment is still considered experimental.
To donate plasma, a person must meet several criteria. They have to have tested positive for COVID-19, recovered, have no symptoms for 14 days, currently test negative for COVID-19, and have high enough antibody levels in their plasma. A donor and patient must also have compatible blood types. Once the plasma is donated, it is screened for other infectious diseases, such as HIV.
Each donor produces enough plasma to treat one to three patients. Donating plasma should not weaken the donor's immune system nor make the donor more susceptible to getting reinfected with the virus. (Tanne, 2020).

Ibuprofen
Some French doctors advise against using ibuprofen (Motrin, Advil, many generic versions) for COVID-19 symptoms based on reports of otherwise healthy people with con irmed COVID-19 who were taking an NSAID for symptom relief and developed severe illness, especially pneumonia. These are only observations and not based on scienti ic studies.
The WHO initially recommended using acetaminophen instead of ibuprofen to help reduce fever and aches and pains related to this Virus infection, but now either acetaminophen or ibuprofen can be used. Rapid changes in recommendations create uncertainty. Since some doctors remain concerned about NSAIDs, it still seems prudent to choose acetaminophen irst, with a total dose not exceeding 3,000 milligrams per day. Ibuprofen boosts the angiotensin-converting enzyme 2 (ACE2), which may facilitate and worsen COVID-19 as a result, WHO initially warned most patients to stick with acetaminophen, which is also known as Paracetamol or Tylenol. However, if you suspect or know you have COVID-19. You cannot take acetaminophen, or have taken the maximum dose and still need symptom relief; taking over-the-counter ibuprofen does not need to be speci ically avoided. (Treatment of COVID19, 2020)

Vitamin C
Some critically ill patients with COVID-19 have been treated with high doses of intravenous (IV) vitamin C in the hope that it will hasten recovery. However, there is no clear or convincing scienti ic evidence that it works for COVID-19 infections, and it is not a standard part of treatment for this new infection. A study is underway in China to determine if this treatment is useful for patients with severe COVID-19; results are expected in the fall. (Peng, 2020) .
The idea that high-dose IV vitamin C might help in overwhelming infections is not new. A 2017 report found that high-dose IV vitamin C treatment (along with thiamine and corticosteroids) appeared to prevent deaths among people with sepsis, a form of overwhelming infection-causing dangerously low blood pressure and organ failure. Another study published last year assessed the effect of high-dose vitamin C infusions among patients with severe infections who had sepsis and acute respiratory distress syndrome (ARDS), in which the lungs ill with luid. While the study's primary measures of improvement did not improve within the irst four days of vitamin C therapy, there was a lower death rate at 28 days among treated patients. (Boretti and Banik, 2020).
Though neither of these studies looked at vitamin C use in patients with COVID-19, the vitamin therapy was given explicitly for sepsis and ARDS, and these are the most common conditions leading to intensive care unit admission, ventilator support, or death among those with severe COVID-19 infections. Regarding prevention, no evidence taking vitamin C will help prevent disease with the Corona Virus that causes COVID-19. While standard doses of vitamin C are generally harmless, high doses can cause several side effects, including nausea, cramps, and an increased risk of kidney stones.

HIV Drugs Combination
Drugs developed to treat HIV are used in the treatment of other viral diseases such as hepatitis B. They have also shown substantial clinical bene it in the treatment of emerging diseases such as severe acute respiratory syndrome, or SARS, which is caused by a Corona Virus similar to that which causes COVID-19. In the race to ind effective treatments or a cure for COVID-19, researchers are now testing antiretrovirals used to treat HIV such as Lopinavir, Ritonavir, and another protease inhibitor called Darunavir.
There is anecdotal evidence to suggest that anti-HIV drugs may be effective. Thai doctors gave Lopinavir and Ritonavir in combination with a lu drug to a coronavirus patient, who tested negative for the virus within two days. In Japan, a patient from Wuhan, China, was treated with just the two HIV drugs and her fever subsided within ive days of being admitted to the hospital. And a report in the journal JAMA in March 2020 showed that three of ive patients recovered after being treated with the same two drugs. (Will HIV Drugs Help Fight Corona Virus? 2020) These reports are encouraging, but public health experts caution that more testing is needed before concluding that HIV drugs can effectively treat COVID-19.

Tulsi leaves
Tulsi leaves are consumable and are being used to normalise Kapha (humour in the body) and Vata (humour in the body). Tulsi is being used in the management of pain diarrhoea cough and fever, which are common symptoms of COVID 19. The leaves, along with cow's ghrita (Ghee) were described for the management of pneumonia. There exists a piece of strong scienti ic evidence for the antiviral effect of Tulsi. Clinical trials conducted earlier in India where the extract of Tulsi leaves was administered for patients with viral hepatitis and encephalitis. Interestingly there was an increase in survival and symptomatic improvement in Tulsi group when compared with controls. Another study proved improvement in respiratory parameters and relief from symptoms of asthma with three days of consumption of Tulsi leaves. Tulsi consumption increases the antioxidant molecules and enzymes in the body and protects the cell and its membrane from being damaged by the toxic substances. Tulsi boosts the immunity and helps to defeat the dangerous virus and bacteria. (Goothy et al., 2020) .

Dinacharya (as a preventive measure)
This is a period to go within so that we can follow our Dinacharya [daily routine]. Wake up early in the morning, brush your teeth, scrape your tongue, rinse your mouth and drink hot or warm water. Have ginger, cinnamon and cardamom tea, regular chai made with Tulsi (holy basil, one or two leaves), or even mint, cinnamon and cardamom tea. These herbal teas boost energy. As long as we keep our Agni (digestive ire) strong, then illness will not happen to us. So, Ayurveda has a great way of prevention as to how we can prevent being affected by the Corona Virus. Keep your Agni strong and, to do that, follow your Dinacharya. It is the irst important thing that Ayurveda recommends.
For Dinacharya, you wake up in the morning, scrape your tongue and brush your teeth. Drink a glass of warm water then do Pranayama. There is a package of eight [bene icial] Pranayama exercises: Bhastrika, Kapala Bhati, AnulomaViloma, Brahmari, Utjayi, Utgeet, and inally Sheetali and Sheetkari. Just by doing this package of eight Pranayama, we can strengthen our immune system, including our Pranavaha Strotas (respiratory system). Rasavaha srotas (lymphatic system) will be cleansed, and that way we can boost our energy. This will maintain the balance of ojas (immunity, strength), Tejas (digestion both subtle and gross), and prāna (vital life force). And there are simple herbal remedies that Charaka has mentioned. Even though there is no common cold, Charaka says that you should take sitopaladi, talisadi, abhrak bhasma, and mahasudarshan churna (Ayurvedic Herbal medicines). Take this preparation, 1 2 teaspoon three times a day or twice a day, every morning and evening. If you are tired, you may not want to do that. You can make a chai and just put a pinch of Sitopaladi or pinch of Talisadi into the chai (tea). It will give a wonderful lavour to the drink. (Lad, 2020).

Surya Namaskara (Salute to the sun)
We can clean our Pranavaha strotasa, our respira-tory system and it will give us a boosting of energy so that we can keep away the virus. Another unusual health-supporting practice is to do some Yogasana (poses in Yoga)-camel pose, cobra pose, cow pose, boat, bow, and bridge pose, locust, lotus, and lion pose. If you think that is too complicated, just do Surya Namaskara. For Surya Namaskara, do a minimum of 7 rounds and a maximum of 12 rounds. We do 7 rounds because there are seven dhatus (bodily tissues). There are 12 essential poses in Surya Namaskara. So, do 12 or 7 Surya Namaskara and then do Pranayama and then sit for meditation. For meditation, you can do So' Hum meditation. For this, sit quietly in lotus pose, siddhasana pose (accomplished) or sahajasana pose (easy), and inhale with the sound "so" in your mind and exhale with the sound "hum". This is a great opportunity. When you do this So' Hum meditation, you will lower the inner joy, the inner beauty. Then sit quietly and feel your presence. (Pratinidhi, 1928).

Ramdev baba [Famous Yoga Teacher in India]
also added that people should do Pranayamadeep breathing, kapalabhati and anulom vilom to increase immunity. It will work best to protect children from the virus.

Chyawanprash [Ayurvedic Herbal medicine]
As people rush to keep themselves protected, Ayurveda experts have stressed that medicinal herbs such as Amla, Giloy, Shilajit and Neem help strengthen the immune system, which is key to ighting the deadly virus. Eating a tablespoon of Chywanprash daily enhances immunity, and it may help prevent the spread of the virus, according to Ayurveda experts.
We all know that strong immunity is necessary to ight any kind of foreign body or disease. Corona Virus primarily affects the lungs and the respiratory system. Eating a tablespoonful of Chywanprash daily enhances the immunity, speci ically that of lungs and the respiratory system. Amalaki or Amla (Emblica Of icinalis), Guduchi/ Giloy (Tinospora Cordifolia), Neem (Azadirachta Indica), Kutki (Picrorhiza Kurroa), Tulsi (Holy Basil) are some of the Ayurvedic herbs that help build the immunity and prevent the infection. It is meant to restore drained reserves of life force (ojas) and to preserve strength, stamina, and vitality while stalling the course of ageing. Chyawanprash is formulated by processing around 50 medicinal herbs and their extracts, including the prime ingredient, Amla (Indian gooseberry), which is the world's most abundant source of vitamin C.
A regular intake of it strengthens the trachea-bronchial tree and hence improves the immunity and functioning of the respiratory system. It helps to treat respiratory infections, allergic cough, asthma, bronchospasm, rhinitis, seasonal or non-season respiratory disorders, common cold, and tuberculosis, and thus strengthens the respiratory system. It is also used as an adjunct to anti-tubercular drugs to augment their bioactivity and prevent their effects.

Rasayana
Rasayana may be employed for ful illing both of protection and promotion of health and curing the diseases. Rasayana is one of its eight branches being practised since time immemorial. Proper Rasayana therapy done with medicines that are collected before the onset of epidemic disease restores physical health. Rasayana drugs are those medicines which are capable of imparting superior Rasas and Dhatus to the body and toning up the system of healthy persons. Rasayana aid in increasing natural immunity, enhancing general wellbeing, improving the functioning of all fundamental organs of the body and keep the signs of early ageing at bay. The primary purpose of Rasayana therapy is to impede the ageing process and to delay the degenerative process in the body. Rasayana is the term given to special herbs, fruits or any other form of medication that are known to promote positive health and longevity. Goyal (Goyal, 2018) .
Truthfulness, compassion for living beings, donation, charity, prayer to the gods, and good deeds, adoption of preventive measures, tranquillity, and protection of the self by Mantra etc. are very effective. Devotion towards God, residence inauspicious localities, observance of Brahmacharya, and service to those observing Brahmacharya are told as a remedy. Discussion on religious scriptures, befriending great sages, who have self-control, who follow a religion, who are Satvika and who are learned, people. These therapies, which, when adopted during epidemic disorders, can easily save lives of individuals provided the epidemics can easily save the lives of individuals provided the death of a particular individual is not pre-determined.

CONCLUSIONS
As the spread of COVID -19 is increasing day by day throughout the world and creating a problematic situation for people. It has nearly affected more than 3.04 million people across 184 countries. Some countries have developed vaccines against the disease. On the other hand, many are trying to rule out a way to recover from this situation. Recommended measures to prevent infection include frequent hand washing, maintaining physical distance from others, covering coughs, and keeping unwashed hands away from the face. Besides, the use of a face covering is recommended for those who suspect with the virus.
People are managed with supportive care, which may include luid therapy, oxygen support, and supporting other affected vital organs, The CDC recommends that those who suspect they carry the virus wear a simple face mask. Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure, but its bene its are still under consideration. Personal hygiene and a healthy lifestyle and diet have been recommended to improve immunity. Supportive treatments may be useful in those with mild symptoms at the early stage of infection.