January 2021

AYUSH Systems of Medicine, a Viable Solution for COVID-19 amidst the Uncertainty of Vaccination & Herd Immunity – an Indian Perspective Hima Bindu Ponnam1* and Butchi Raju Akondi Homoeopathic Clinical Research Unit, Central Council for Research in Homoeopathy, Under Ministry of AYUSH, Government of India, Hyderabad, Telangana, India; drdewdrop@gmail.com Department of Clinical Pharmacy and Pharmacology, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia; drraju2020@gmail.com In this era of major modern medical advancements, a way of lurking uncertainty still persists about human life in combating the upcoming novel viral diseases as present SARS-CoV2 virus causing COVID-19. COVID-19 tremendously pushed the whole world into a wave of anxiety and stress in terms of uncertainty about life and death. As on 17th May 2020, in India, the infected cases are 90,927 amongst which active cases 53,946, deaths are 2872, and cured discharged cases are 34,1081. The Case fatality rate as on this date is around 3.2% in India and the recovery rate is 37.5% which seems to be very positive when compared with other suffering countries of the world. A precise introspection in this regard is very much essential at this juncture of endangered human life. Before analyzing the fact, lets us see why such an immense uncertainty prevailing regarding the treatment of COVID-19 and its containment. The last 2-3 months of fact sheet enabled us to understand that 81% of cases of COVID-19 were asymptomatic, 14% severely exhibited with symptoms and only 5% needed critical care. At this stage where no known established treatment regimen is prevailing, the management of COVID-19 remains a challenge to the whole world. The treatment approach presently being utilized world-wide is the allopathic system of medicine with different opinions from experts including retroviral medicines combination used in HIV cases & remsedivir developed for Ebola), Hydroxy-chloroquine (HCQ). These broad-spectrum antibiotic regimens being used currently are meant for treating bacterial infections coming after a virus attack but not to treat COVID-19 directly and they pose a lot many adverse side effects as on record. In critical cases, oxygen therapy, intravenous fluid infusion, and life-saving ventilator therapy are being utilized in combination as per the condition of the patient. Leaving aside the treatment options, let us evaluate the other possible strategies for the containment of the virus. The most awaited and the discussed option is the Vaccination which is under different phases of trials in different countries at present. Vaccination is the administration of a vaccine to help the immune system develop protection from a disease and it contains a microorganism or virus in a weakened, live or killed state, or protein or toxins from the organism. When we go through the history of vaccinations, it is evident that preparing a vaccine for an epidemic is a lengthy and expensive process, which may take about a year or two or even more. Also how far the vaccination would succeed is doubtful on account of different strains of the virus and also a study by Li and her collaborators recently found it evident that the SARS-CoV2 virus has acquired mutations capable of substantially changing its pathogenicity and also its mutations again throwing us into uncertainty. Coming to the Herd Immunity (HI), a much-out spoken concept by many expert epidemiologists. Herd Immunity happens when so many people in a community become immune to an infectious disease that it stops the disease from spreading. It happens in two ways: one is that many people contract the disease and in time build up an immune response to it (natural immunity) and the other many people are vaccinated against the disease to achieve immunity. As we already discussed the option of vaccination which have a higher chance of failure. Coming to the natural herd immunity, in which we are leaving the population at risk to contract the disease. Again this depends on the average number known as the basic reproductive number commonly symbolically designated as “R0” – that is the average number of other persons that an infectious person will infect with an agent in a completely susceptible population. This may become very risky when the clinical consequences of the infection are greater for the vulnerable low immunity groups (children, old age, and pregnant women). The United Kingdom initially opted for it but in view of the fatal consequences of increasing mortality rates had to withdraw opting for lockdown restrictions in their country. Ultimately, herd immunity option also exhibits a risk of mortality and uncertainty. Finally comes the much-weighted statement about COVID-19 prevention is possessing a natural strong immunity within the human body. Moving into the introspection of the Indian perspective, India is a country full of rich ancient culture and heritage lasting from thousands of years. Many ancient scriptures envisaged the use of a vast number of natural remedies in boosting the immunity of a person. In India when we critically observe the treatment regimens opted for, it has been found that a considerable amount of people give preference to Ayurveda, Yoga, Unani, Siddha, Sow Rigpa, and Homoeopathy (AYUSH) systems of medicine which are the rich heritage of India. Even the Indian Government supports these systems of medicine under the National Health Mission and taken necessary steps to mainstream these systems of medicine to bring an equal status to the allopathic system of medicine. The Indian government has formed a separate Ministry of AYUSH in 2014 to strengthen the potential of these systems of medicine in reaching the masses. The Confederation of Indian Industry website states that the AYUSH is currently a $10 billion market and is expected to grow to a $15 billion market by 2020 (https://www.ciiblog.in/industry/ayush-is-booming-in-india/). According to AYUSH systems, the common reasons for preferring these treatment options includes lesser side effects, effective disease management, and improvement of quality of life and health promotion, higher preventive potential, and cost-effectiveness. All these systems are highly known for their holistic approach of treatment and their main modus operandi of remedies is to strengthen the natural immunity of the individual which in turn stimulates the human body to fight with

Immunity against COVID-19: Potential role of Ayush Kwath Shankar Gautam, Arun Gautam, Sahanshila Chhetri, Urza Bhattarai a) Ministry of Health and Population, Kathmandu, Nepal b) Ministry of Social Development, Gandaki Province, Nepal c) TU Ayurveda Teaching Hospital, Kirtipur, Nepal d) MCOMS, Pokhara, Nepal Abstract SARS-CoV-2 infection associated respiratory disease- COVID-19 has evolved into a pandemic but, being a new form of virus, pathogenesis of disease causation is not fully understood and drugs and vaccines against this virus are still being tested so that no effective drugs or vaccines have been advised by regulatory authority. In this context, the Ministry of AYUSH, Government of India has recommended ‘Ayush Kwath’ to improve the immunity and combat the infection. Our objective of this literature review is to review the role of immunity in pathogenesis of COVID-19 and role of Ayush Kwath against the virus and regulation of immunity. Current review was conducted using a search of available literature on COVID-19 and immunity, Vyadhikshamatwa, Ayurveda and COVID-19, Rasayana, Coronavirus, SARS-CoV-2, immunomodulatory effects of medicinal plants; Tulsi/Holy Basil/Ocimum sanctum, Dalchini/Cinnamon/Cinnamomum zeylanicum, Sunthi/Ginger/Zingiber officinale and Marich/Black Pepper/Piper nigrum. Ayur-veda, being an ancient science have both medicinal and cultural values and had stimulated our kitchen and influenced what we ate in different seasons and the remedies we used for common ailments. Herbs such as Tulsi, Marich, Sunthi, Dalchini are the most commonly used and easily available drugs in home. Thus, Ayush Kwath due to its immune-modulatory, antiviral, anti-oxidant, anti-inflammatory, anti-platelet, anti-atherosclerotic, hepato-protective, reno-protective properties; seems to be effective in immuno-regulation for controlling viral infections like COVID-19. Further pre-clinical and clinical trials need to be done for the evaluation of safety and efficacy of this polyherbal formulation. © 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda Foundation. This is an open access article under the CC BY-NC-ND license 1. Introduction COVID-19, also known as severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is an infectious disease believed to be originated from bats and transmitted to human beings [1]. Being a new form of virus, pathogenesis of disease causation is not fully understood and drugs and vaccines against this virus are still being tested so that no effective drugs or vaccines have been advised by regulatory authority. Not only for Coronavirus, have many other viruses also lack preventive vaccines and effective antiviral medications. Studies have explored that these viruses can form drug-resistant mutants, which decrease the existing drug’s efficacy. So, these viruses can be a threat to the mankind for long time [2]. High mortality among immune-compromised and those with some underlying pathology implies that the factors that improve immunity can prevent serious manifestations due to COVID-19 infection [3]. Many herbal products are found to have immune-modulatory and antiviral property, so their discovery can be a milestone in the prevention and control of COVID-19 [2]. In this context, the Government of India has recommended to take ‘Ayush Kwath’ in order to boost the immunity. As this is a new formulation, this needs to be validated scientifically. We have made an attempt to review the immune-pathogenesis of COVID-19 and the role of each herb over it. 2. Immunopathogenesis of COVID-19 The ‘S’ protein of coronavirus can bind to host cells through the ACE2 receptor found in the oral and nasal mucosa [1,4]. Other sites where ACE2 receptors are found are lungs, stomach, intestine, bladder, heart, and kidney [5]. Variable presentation of disease in different age groups, serious manifestations that are seen more commonly in immune-compromised, old aged and in those with underlying pathology, many asymptomatic cases in pediatric age group, and presence of lymphopenia in the majority of the cases; these factors implies that immunity has a vital role in the patho-genesis of COVID-19 [1,6e8]. It is assumed that our immune system has lack of memory against such a virus that gave it an edge over humans [3]. Viruses cause cell destruction mainly in two ways; direct cyto-pathic effects of the virus and immune response mediated destruction [9]. COVID-19 cannot lyse the cells directly as the major pathway of cell destruction is due to immune-mediated destruction [10,11]. It has been mentioned that unlike adults, less vigorous cell-mediated immune response in alveoli of children results in being asymptomatic in the majority of cases [3]. The pathogenesis can be split into two stages: Non-severe and Severe [12]. 2.1. Non-severe stage The virus fuses with the host cell membrane and enters inside the host cell through airway epithelium [13,14]. The virus propagates and multiplies inside the host cell and can reach lower airway and alveoli. In adults with good innate cellular and humoral immunity propagation of virus can be limited and viral load reaching alveoli can be reduced thus recovery can take place within 2e3 weeks with mild symptoms [3]. Humoral immunity prevents the viruses to enter new cells while cell-mediated immunity targets on eradicating virus-infected cells [1,15]. In this stage, a strong immune system can be helpful in preventing the propagation of the virus thus reducing the severity of the disease [12]. 2.2. Severe stage Once the immune system is breached, the virus propagates and reaches the lower respiratory tract and alveoli. Then the virus can penetrate alveoli and reaches systemic circulation causing viremia [3]. The virus binds to multiple organs having ACE2 receptor protein. During this stage, cell-mediated immunity becomes robust and starts releasing various pro-inflammatory cytokines (IFN-a, IFN-g, IL-1B, IL-6, IL-12, IL-18, IL-33, TNF-a, etc.) and chemokines (CCL2, CCL3, CCL5, CXCL8, CXCL9, CXCL10, etc.) causing damage to multiple organs known as Cytokine storm [16,17]. We may need to suppress the inflammation for improvement during this severe stage [12]. IL-6 receptor antagonist (Tocilizumab), and anti-inflammatory interleukin (IL-10) are proposed to have a thera- peutic role in the reduction of severity and mortality of COVID-19 [18,19]. As increased risk of thromboembolic phenomena is also found to be associated with COVID-19, prophylactic antithrombotic medications are advised during this stage [20]. 3. Ayurveda purview 3.1. Disease concept It seems that most early cases had a history of contact with the original market for seafood, but the disease has now advanced to

Patients Globally Seek Accessibility to Indigenous Alternative Medicine Systems as an Option to Stay Healthy By Prof. Bejon Kumar Misra, Former Board Member International Alliance of Patients’ Organisations (IAPO), New Delhi, INDIA. The Covid-19 pandemic has caused immense disruption to our social and working lives. As we battle through these challenging times, we are being confronted with increasing questions and views as to how this pandemic will impact the healthy citizens and asymptomatic carriers. Of those of us that get symptomatic, it appears that we’re shedding significant virus in our oropharyngeal compartment, probably up to 48 hours before we show symptoms. Thus it explains how rapidly this virus continues to spread across the country because we have asymptomatic transmitters. Enhancing the body’s natural defence system (immunity) plays an important role in maintaining optimum health. While there is no medicine for COVID-19 as of now, the Indian Government’s Ministry of AYUSH recommended self-care guidelines for preventive health measures and boosting immunity with special reference to respiratory health. These guidelines were supported by Ayurvedic literature and scientific publications, which initiated an International Seminar on AYUSH from 27th April to 2nd May 2020 organised by the members of IAPO. The seminar brought out a NINE POINT MAHAMANA DECLARATIONS on “The Role of indigenous alternative medicine systems in India, Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (abbreviated as AYUSH) in fight against Corona Virus globally”. The focus was on how to access indigenous alternative medicine systems AYUSH to lessen morbidity and mortality in 1.39 Billion consumers in India. Several suggestions were proposed to upgrade the capacity and adopt four-prong strategy on preventive interventions, novel scientific studies to prepare drug/ nanoparticles against SARS-CoV-2, Immunity by improving our immune system by daily intake of immune boosters viz., Gudhuchi kwatha, Chyavanprasha, Tulsi, Parijata, Chirayita, Turmeric powder, Zinger, Lemmon etc. and finally Up-scaling and marketing of plants with their medicinal value through Plant Tissue Culture strategies and technology transfer. The holistic approach of AYUSH systems of medicine focuses on prevention through lifestyle modification, dietary management, prophylactic interventions for improving the immunity and simple remedies based on presentations of the symptoms. For instance, emphasis on avoidance of causative factors and enhancing the immunity against host of infections are characteristics of Ayurveda management. The preventive aspect of Homoeopathy is well known, and historically, Homoeopathy has reportedly been used for prevention during the epidemics of Cholera, Spanish Influenza, Yellow fever, Scarlet fever, Diphtheria, Typhoid etc.