China has done well in infection control since the early part of the COVID-19 pandemic. Apart from the strict, rather drastic measures of isolation, containment, and restrictions, there is a general belief that the integrative use of Traditional Chinese Medicine has helped to give better treatment outcomes.
The use of integrated treatment has been endorsed and guided on a national level and supported by the general public. Experts recommended specific choices of herbal formulae to be used at different stages of infection — mild, moderate, and severe.
Historical accounts on the clinical effectiveness of herbal medicine to infections are plentiful in China, particularly for respiratory infections. In the past decades, many widespread influenza epidemics in China have involved extensive uses of Traditional Chinese Medicine with many apparent merits. For example, the recent SARS crisis of 2003 saw 60 per cent of infected patients in China receiving Chinese Medicine treatment. Subsequent analysis of the clinical value revealed the remarkable efficacies of its supportive role on fever, cough, and other symptomatic control.
In contrast to the rich reports on the treatment efficacies and varieties of herbal choices, little has been described on the specific use of Chinese Medicine for the prevention of infection in individuals. If herbal treatment prevents the progress of the mildly affected into the moderate stage, that would be equivalent to the prevention against very early infection and would lead the way to a strict Prevention Consideration. During the SARS epidemic, strict preventive attempts using Traditional Chinese Medicine have, on some occasions, very positive results.
It is suggested that the role of Chinese Medicine in the treatment of COVID-19 patients should be seriously analysed and further researched to produce solid evidence of treatment efficacy in preparation for the next epidemic.
Equally important would be the creation of an evidence-based Preventive Herbal Preparation to resist future infections attacking individuals. This innovative preparation is different from the vaccine, which aims directly at the invading virus or organism. Instead, herbal medicine boosts the innate immunity of the individual to strengthen his or her existing defence ability. Traditional Chinese Medicine is highly supportive of the philosophy of self-defence, that is, to be fully equipped to meet the coming aggression. We look forward to seeing experts in China take up this important role in preparation for the next epidemic/pandemic.
Early Containment of COVID-19 Spread in China
China in the early phase of the pandemic (early 2020), has managed this public health crisis well in that the infection was contained mainly in the Hubei province. The emergency provision of medical facilities was adequate, and the infection and mortality rates compared with subsequent data were well lower than expected.1,2,3 China appeared to be freed from the COVID-19 pandemic for up to a year. If not for the recent reappearance of some cases in 2021, the superiority of the pandemic control in China could be considered effective and admirable. Now, we have to wait and reconsider.
Contribution of Chinese Medicine
Observers and experts have been trying to analyse how did China manage to have effective control of the COVID-19 pandemic. Apart from the strict rules and practices on person-to-person separations and lockdowns, there could be special reasons related to the use of integrative medical treatment, viz. adding Traditional Chinese Medicine to standard hospital care, giving superior results in not only treatment outcome, but also in preventive measures.4,5 The practice of integrative care came not only from personal decisions but was also given to the broad medical fraternity in the form of National Guidelines.6,7
In the National Guidelines, there were general recommendations to be optimised under Provincial Guidelines. The review on the 26 national/provincial guidelines showed that the infection was labelled as early, intermediate, severe, or rehabilitation stage and specific choices of integrated treatment were given.8
During the severely affected period of early 2020, it was estimated that 92.6 per cent of infected patients received integrative treatment. Many hospitals sharing the care of COVID-19 patients claimed that integrative treatment gave better recovery and survival.9 Many herbal formulations were advocated for different varieties of treatment and many clinical trials have been organised to testify the validities of various integrative treatments.10,11 Moreover, several medicinal herbs believed to command key positions in effective formulae used for treating COVID-19 patients have been put under the research platform to reveal their specific role in molecular studies and define their mechanisms of action.12
From the experience of medical professionals to the official national evaluation, the overall consensus is that the successful control of COVID-19 infection in China can be attributed to the use of Chinese Medicine in the integrative care of patients.13 As the urgent need for the containment of infection spread and care for the infected eased, scientists and clinicians gathered hospital information and analysed the role of Chinese Medicine in the overall treatment protocols. Their subsequent reports tended to give full merits to the use of Chinese Medicine. However, well-planned studies on integrative treatment compared with no Chinese Medicine treatment on small scales are available for objective evaluations.14 Expert pharmacologist on clinical therapeutics Y.C. Cheng from Yale University had carefully scrutinised the treatment reports advocating the use of Chinese Medicine and was convinced about the genuine potential of integrative treatment to reduce the time required to get a good result for active COVID-19 treatment from secondary infections, complications, and duration of dependence on mechanical ventilation.15
Historical Accounts Support the Value of Chinese Medicine
Since 1911, seven epidemics of influenza infection have happened in China: four (1918, 1957, 1968, and 1977) of which affected not only China but also other countries, while three others affected China alone (1997, 1999, and 2003). The 1918 pandemic was the most damaging pandemic ever reported of the influenza virus origin, though China was not as severely hit as other regions in the world. One reason given for this observation was that since modern medicine was not well-developed and no vaccine was available, Chinese Medicine could have contributed to the control of the infection.16 Since 1949, during the influenza epidemics in China, strong national encouragements for the use of Traditional Chinese Medicine at different stages of the disease formed the national policy. Since influenza has a universally low mortality rate, the value of Chinese Medicine presumably could be related to symptom control and prevention of complications.17 Mild cases could be relieved using herbal treatment alone, while moderately severe and severe cases would need to be managed with modern treatment and hospitalisation.18
During the 2003 SARS epidemic in Hong Kong, a clinical trial using herbal medicine for prevention was conducted. Details of the trial are given as follows:
As a means to protect the at-risk hospital workers, an innovative herbal formula was created by combining two classical formulae popular for the treatment of cold and influenza-like infections, and given to 3,160 workers for consumption over two weeks. During the two weeks, infection symptoms and adverse effects were closely monitored. One month later, it was shown that none of the herbal consumers contracted the infection whereas 0.4 per cent of the non-consumer controls were infected.19 The immunological states of 37 of the herbal consumers were studied serologically before and after the herbal consumption. The researchers confirmed that the innate immunological state of the consumers improved, and the adverse effects were found to be insignificant.20
In a subsequent follow-up, immunological studies on the same formula gave further evidence of its immunological boosting effects.21 In any epidemic of respiratory disease, it is not easy to organise proper clinical trials. The Hong Kong study during the SARS crisis in 2003 succeeded in giving early objective indications that classical antifebrile herbal formulae could be useful in an epidemic to provide personal protection against the contraction of the highly contagious disease.
During the SARS crisis in China (2007), 60 per cent of infected patients received Chinese Medicine treatment at some stage of the disease. Published reports have been reviewed to clarify the role of Chinese Medicine within the overall delivery of treatment. It was observed after reviewing 130 articles that Chinese Medicine was mainly used as adjuvant treatment for the control of fever, clearance of chest infection, soothing cough and intestinal complications, and lowering the consumption of steroids, instead of as the main therapeutic agent.22 Therefore, it was speculated that the role of Chinese Medicine, apart from being supportive as an adjuvant, could be more directed towards preventive care as it is effective in very mild cases.
We could agree that the experience gathered in the current pandemic together with the historical records support the strong claim from China that integrating Chinese Medicine into clinical practice has been an effective means to achieve better results. The optimistic beliefs, however, are based on treatment aspects, not on prevention23.
Prevention Using Chinese Medicine
During this COVID-19 pandemic, epidemiologists in China have discussed using Chinese Medicine for the prevention of future infections24. After all, one important aspect of the philosophy of Chinese Medicine is disease prevention. However, they were only able to find three well-designed clinical trials performed in the recent SARS epidemic directly aiming at prevention.25,26 The scanty literature does not offer much in subsequent endeavours. Past experiences on prevention have failed to offer guidance and references for mainly three reasons. Firstly, the Chinese language in the classical records used to integrate prevention with treatment, and public health issues and environmental effects were not well defined.27,28 Secondly, clinical evidence for the prevention of infections in the recent decades are missing. Thirdly, in the current outbreak, prevention is confined to the early stage of the disease, not before the occurrence of symptoms. Early-stage “prevention to deteriorate” is handled with established treatment methodology involving complicated herbal combinations, which do not favour preventive measures before acquiring the infection. Chinese Medicine experts also insist on patient “pattern” diagnostics to verify and individualise prescriptions, which do not favour large-scale prevention.29 The best choice for a herbal preparation to be used for prevention would need to be simple, uniform, and good for all.
Role of Chinese Medicine in Future Epidemics
Future epidemics, like the current one, could be caused by newly identified viruses. However, as effective conventional treatment is lacking, we can turn to alternative forms of treatment like Chinese Medicine. With its strong historical background, holistic principles of multiple targets approach, and emphasis on immunological support and balance, Chinese Medicine could serve as a safe choice for early remedy until more clinical and pathological facts are revealed. During the SARS epidemic and the current COVID-19 pandemic, the merits of Chinese Medicine supplements and treatments have been well appreciated.30,31 In preparation for future epidemics, the accumulated experience should be reviewed and analysed, followed by properly designed clinical trials and laboratory studies to establish firm support for effective formulations and choices. The current recommendations could be acceptable for clinical practice in China but the complicated choices, formulations, and even herbal injections are certainly beyond the appreciation of experts outside China, not to mention “syndrome-based,” “pattern-based” diagnoses and prescriptions. Let the recommendations be provided with evidence-based research records coupled with clear descriptions within the expectations of modern clinicians, who demand diagnostic and assessment tools like imaging and laboratory data.32
On the prevention side, a vaccine-like prevention concept could be adopted so that the innate immunological defence ability of the individual could be strengthened, and symptom development would not have a chance at all. One expects a simple formulation with a few herbal items, preferably orally-fed, safe, and without adverse effects. The development of this preventive supplement needs classic references related to epidemics and laboratory studies to verify its specific effects, particularly regarding immunological support, and clinical studies to gain genuine evidence and safety confirmations.33,34
Integrating Traditional Chinese Medicine with Modern Clinical Practice has always been a national policy in China which, throughout the decades under the People’s Republic, has enforced a stable establishment of the two streams in well-calculated proportions in areas including education, services, and infrastructural provisions.35 On one hand, modern medicine has been advancing fast in pace with global developments. On the other, Traditional Medicine has been keeping its conservative line and would unavoidably appear to be obsolete. This reality affects a good integration.
Services given by Chinese Medicine doctors have been extremely popular as are exemplified in the relevant clinics and out-patient departments of Chinese Medicine hospitals. However, other services in the Chinese Medicine hospitals are overwhelmed with modern investigatory requirements, pharmaceutical provisions, and surgical procedures.36
A review of the current pharmacy market relevant to herbal products and formulations would provide a vivid picture of Traditional Chinese Medicine from another practical angle. Classical formulae and their modifications are registered under the State Registry for Medicinal Products. In 2020, a total of 9,629 Chinese Medicine proprietary items are recorded and produced by 2,856 industries. These numbers are declining. Most of the registered items are ancient formulae that are short of innovative modifications. Large industrial producers are only limited to 15.37 The small number reflects that despite the persistent popularity of Chinese Medicine, service innovation is declining and industrial enthusiasm seems worrying.38
Decision-makers must be aware of the discrepancies leading to a down-grading of Chinese Medicine in the overall health care system.
Political leaders in China voiced out repeatedly the importance of Chinese Medicine and its further development. But it was only as late as 2016, that the People’s Congress passed legislation on Traditional Chinese Medicine, governing the development, rules, and regulations related. Since then, the legal protection and planning, from education, professional development, special services and integration into the mainstream etc., are updated and fully endorsed. According to the Chinese Premier, this development is an “extra-important enterprise.”39,40
Given the rather disappointing reality related to the professional integration despite the Central Policy and Official Support, the current pandemic is giving Traditional Chinese Medicine a wonderful opportunity to respond to the urgent need to reach solid recognition.
On the treatment side, the genuine value of Chinese Medicine used alone or supplementing modern treatment against the pandemic has been well endorsed and evidence is still accumulating. The varieties of herbal formulae should be good for respiratory tract infections under different circumstances, including the next epidemic. The accumulated knowledge gained should be further clarified and expressed in presentations to be shared by all clinicians. The professional language used should be appealing to the modern practitioners, who might not know Chinese Medicine. As Professor Cheng at Yale University commented in October 2020, “The clinical results of integrated treatment against COVID-19 are good demonstrations of the synergy. Further studies in international, multicentre clinical and scientific settings are very much needed.”15
On the prevention side, the creation of a simple herbal medicinal supplement that is capable of boosting the innate immunity of the individual to resist invading organisms is an urgent task, in preparation for the next epidemic. Although Traditional Chinese Medicine emphasises treatment in ancient times, today, our knowledge on immunological defence could guide us on the choice of appropriate herbs known for boosting immunity that can be placed onto evidence-based research platforms, followed by clinical trials, in a timely creation of vaccine-like supplements.41 Since nutritional components like vitamin D, are well-established supportive agents against respiratory infections, combining Chinese Medicine with such nutrients to attain synergy will be another innovative practice of integration.42,43 [APBN]
- Dawei Wang, Bo Hu, Chang Hu, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-1069. DOI: 10.1001/jama.2020.1585
- Yuan Gao, Qi-Yong Liu. The Epidemic Dynamics of 2019 Novel Coronavirus (2019-nCoV) Infections in China by 28 January. January 2020 SSRN Electronic Journal. DOI: 10.2139/ssrn.3529448
- Nanshan Chen, Min Zhou, Xuan Dong, Yang Han, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-513. DOI: 10.1016/S0140-6736(20)30211-7. Epub 2020 Jan 30.
- National Health Commission of People’s Republic of China. Announcement of the National Health Commission (No. 1 in 2020). http://www.nhc.gov.cn/iki/s7916/202001.
- Yang Yang, Sahidul Islam, Jin Wang, Yuan Li, Xin Chen. Traditional Chinese Medicine in the Treatment of Patients Infected with 2019-New Coronavirus (SARS-CoV-2): A Review and Perspective. Int J Biol Sci. 2020; 16(10): 1708–1717. DOI: 10.7150/ijbs.45538
- National Health Commission of People’s Republic of China. Diagnosis and treatment of pneumonia caused by 2019 coronavirus. 2020/1/22 http://download.caixin.com/upload/feiyandisanban.pdf
- National Bureau of Traditional Chinese Medicine. Diagnosis of COVID-19 pneumonia. [EB/OL] 2020.
- Kam Wa Chan, Vivian Taam Wong, Sydney Chi Wai Tang. COVID-19: An Update on the Epidemiological, Clinical, Preventive and Therapeutic Evidence and Guidelines of Integrative Chinese-Western Medicine for the Management of 2019 Novel Coronavirus Disease. Am J Chin Med. 2020;48(3):737-762. DOI: 10.1142/S0192415X20500378.
- Tang X, Li X, Zhao L, Zhao Y. Discussion on Traditional Chinese Medicine prevention and treatment strategy. J Tradit Chin Med 2020 http://kns8.cuki.net
- National Administration of Traditional Chinese Medicine. Progress in screening of effective prescriptions of Chinese Medicine. National Administration of Trad Chin Med, Beijing 2020b.
- Li C, Shang H. Research projects of Chinese Medicine injection in treating COVID19. Med Tradit Chin Med Mater Med 22:1-6, 2020a
- Chan H, Du Q. Potential natural products for preventing 2019 COV19 infection. 20200 10358:2020
- Ming Niu, Rui-Lin Wang, Zhong-Xia Wang, Ping Zhang. Rapid establishment of traditional Chinese medicine prevention and treatment of 2019-nCoV based on clinical experience and molecular docking. DOI: 10.19540/j.cnki.cjcmm.20200206.501
- Zhao Jing, Tian J, Yang J, Zhang W. Investigating mechanism of Qing-Fei-Pai-Du-Tang for treatment of novel coronavirus pneumonia by network pharmacology. Chin Trad Herb Drugs 2020. http://kns.cnki.20200216
- Cheng, YC. Integrative Medicine Demonstrates Advantage in COVID-19 Treatment. Chin. J. Integr. Med. 26, 805 (2020). https://doi.org/10.1007/s11655-020-3432-9
- K. F. Cheng, P.C. Leung, What happened in China during the 1918 influenza pandemic? Int J Infect Dis. 2007 Jul;11(4):360-4. DOI: 10.1016/j.ijid.2006.07.009
- Ping-chung L (2020) Epidemic Diseases and Chinese Medicine – From Ancient to Current Time. J Trop Med Infect Dis 1: 001. 10.29011/JTMID-101.100001 https://asteroidpublishers.com/uploads/articlepdfs/JTMID-0019788.pdf
- Zhang JH, Su TM, Fan WY (2006) Analysis of research reports on the use of herbal medicine for the treatment of Influenza. China J on Informations of Chinese Medicine (in Chinese) 13: 103-105.
- Lau TF, Leung PC, Ko WM, Fong C, Cheng KF, et al. (2005) Using herbal medicine as a means of prevention- Experience Drug the SARS crisis. Am J Chin Med 33: 345-356.
- KP Fung, PC Leung, KWS Tsui, CCD Wan, KB Wong, MYM Waye, WNS Au, CK Wong, WKC Lam, BSC Lau. Immunomodulatory activities of the herbal formula Kwan Du Bu Fei Dang in healthy subjects: a randomised, double-blind, placebo-controlled study. Hong Kong Medical Journal. Feb 2011, 17(Supp 2): 41-43 HHSRF: 02040332
- Poon PMK, Wong CK, Wong ELY, Leung PC, Lam WK, et al. (2006) 20. Immunomodulatory Effects of a Traditional Chinese Medicine Formula with Potential Anti Viral Activities. Am J Chin Med 34: 13-21.
- PC Leung. The Efficacy of Chinese Medicine for SARS: a review of Chinese Publications after The crisis. The America Journal of Chinese Medicine. 2007 Vol.35, No.4, pp.575-581
- Ping-Chung L, Chung-Lap Ben C, Chun-Kwok W. Clinical Use of Chinese Medicine in the Current COVID-19 Crisis and Related Research Planning. Clinical Research in Infectious Diseases. Clin Res Infect Dis 2020, 5(1): 1054
- Luo H, Tang QL, Liu JP, 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 Feb 17 : 1–8. DOI: 10.1007/s11655-020-3192-6
- Xu J, Jiang X, Zhang W. Clinical observation of Yinhua Yupingfeng Decoction in preventing SARS. Conference on the prevention and treatment of SARS in integrated traditional Chinese Medicine and Western Medicine in five provinces of North China. Beijing 2006:158-169.
- Zhang L, Chen B, Zeng H. Analysis of fandu decoction on SARS and zero infection in hospital. Ch J Hospital Pharm (Chin) 2005:25:59-60.
- Wang WY, Yang J. An overview of the thoughts and methods of epidemic prevention in ancient Chinese Medicine. Jilin J Tradit Chin Med (Chin) 2011;31:197–199 28. J NEEDHAM, L GWEI-DJEN. Hygiene and preventive medicine in ancient China. J Hist Med Allied Sci. 1962 Oct;17:429-78. DOI: 10.1093/jhmas/xvii.4.429. 29. Ou AH, Lu CJ, Li XY, et al. Analysis on the Chinese medicine syndromes and demographic characteristics of patients with influenza-like illness in clinics of China. Chin J Integr Med 2014 Feb;20(2):101-6. DOI: 10.1007/s11655-013-1582-8.
- WHO. Clinical trials on treatment using a combination of Traditional Chinese Medicine and Western Medicine. WHO, Geneva, 2004:1-194.
- National Health Commission. National Health Commission and National Administration of Traditional Chinese Medicine. Diagnosis and treatment of coronavirus pneumonia (version 6) 2020.
- Leung PC. Methodology for the Development of Evidence-based Herbal Tonics for Preventive Purposes. HSOA Journal of Alternative, Complementary & Integrative medicine 2015, 1: 004, pp1-5 DOI:10.24966/ACIM-7562/100004
- Leung PC, Chan CL, Wong CK. Immunological Defence beyond Vaccination- A Review. J Vaccines Immunol 2020, 6(1): 018-021. DOI: https://dx.doi.org/10.17352/jvi.000031
- Chan CL, Leung PC, Cheng KF, Wong CK, et al. Going Along the Direction of Trained Immunity – a Herbal Supplement for the Prevention of Respiratory Infection. J Vaccines Immunol 2020 6(1): 032-037. DOI: ttps://dx.doi.org/10.17352/jvi.000035
- Leung PC. State of Chinese Medicine in China Today. Book Chapter in: A Comprehensive Guide to Chinese Medicine, 2nd Ed. World Scientific Publishing CO. PTE. LTD 2015.
- Leung PC. Developing Hong Kong into a Chinese Medicine International Platform. A Special Report from the Institute of Chinese Medicine, 2008 The Chinese University of Hong Kong.
- National Administration for the Control of Drugs. Simplified Regulations for the Registration of ancient herbal formulae. National Administration for the control of Drugs (Chinese) 2018-05-29.
- Tsang Q, Yang AD, Zhou JN. Analysis of data related to the marketing of Ancient Herbal Formulae. Chinese Med Clinical Pharmacology 2020, 36(3) (Chinese)
- Legislation on the Development of Chinese Medicine. National of China Documentation 2016.
- Special Report from Expert Commutator. J of Peoples Congress 2021/4/20.
- Ben Chan , CK Wong, PC Leung. What can we do for the Personal Protection against the CoVID-19 Infection? Immuno-Boostering Specific Supplement could be the Answer. J Emerg Med Trauma Surg Care 2020, 2: 007
- Study confirms Vitamin D protects against colds and Flu. The Harvard Gazette: 2017
- Leung PC, Wong CK, Chan CL. Therapeutic Protection against COVID-19 Infection While Waiting for Herd Immunity. J of Community and Preventive Medicine, Vol 4:(1) 2021
About the Author
Dr. Ping-Chung Leung is the Director of the State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants (The Chinese University of Hong Kong), funding of which is provided by the Innovation and Technology Commission of Hong Kong.