Medical & Clinical Reviews

Keywords

Coronavirus; Covid-19; Unani; Amraz-e-Waba; Nazla Wabaiya; Humma Wabaiya; History; Influenza; Immunomodulatory herbs; Air purification; Antiviral; Prevention; Immunity enhancer; Epidemic; Pandemic

Introduction

The ongoing pandemic Corona virus disease (Covid-19) is a public health emergency of international concern and has posed a major challenge to global health issue. It’s a Novel infection which is caused by SARS CoV-2 with serious clinical manifestation i.e. fever, cough, cold, malaise, respiratory distress, organ failure further may result into death. Environmental factors such as air pollution, smoking and other systemic illness (DM, HTN, CKD, Asthma) likely increase the severity of Covid-19. Immune response is essential to eliminate virus and to preclude disease progression to severe stages. Therefore, strategies claim to boost immune response are certainly important [1].

The incubation period of Covid-19 ranges from 1 to 14 days, averaging 5-6 days in most patients, though an incubation period of up to 24 days has been reported in some cases [2]. The disease affects males and females equally, although a slight male predominance has been observed [3].

Most patients have a good prognosis, with mild flu-like symptoms [4]. However, a small percentage, particularly the elderly and those with underlying diseases may develop complications such as arrhythmia, shock, acute renal failure, acute cardiac injury, acute respiratory distress syndrome, etc.[3]. Overall, the case fatality rate is estimated to be 2-3% [5], while it is as high as 8-15% in older adults [4].

The disease is thought to be mainly transmitted through infected droplet, fomites andoro-fecal transmission, touching and shaking hand with infected individual are also speculated for the infection[6]. Researchers have also believed that virus may transmit via fluids. i.e. mucus. Symptoms appear after an incubation period of two weeks. During this period virus replicates in the upper and lower Respiratory tracts. Common symptoms in infected individual include fever, cough, sore throat, running nose, breathlessness and the lesion in the lungs [6-12]. China's first case of Covid-19 has been traced back to November 17 last year, reports South China Morning Post quoting government data [13]. On 12 March 2020 Covid-19 was declared a pandemic by World Health Organization WHO. Bangladesh reported its first confirmed COVID-19 case on 08 March 2020.It reached 100 cases on 09 April, and exceeded 200 cases within the next 2 days [14]. Bangladesh reported its first confirmed COVID-19 death on 18 March 2020, just after 10 days of reporting the first COVID-19 confirmed case [15]. Till yet no specific drugs verified for SARS-CoV-2, so emphasis is given on preventive measures and symptomatic treatment [2]. In this context, traditional systems of medicine are being explored for providing preventive, supportive and rehabilitative care to the patients. Although no direct evidence is available, some uncontrolled studies on traditional medicines suggest that they have a number of pharmacologically active substances and thus may have a direct therapeutic effectagainst the virus [16]. Unani medicine is one of the officially recognized traditional medicine system here in Bangladesh.

About Unani Medicine

Unani system of medicine has its roots in ancient Greece, in the teachings of Hippocrates (460-377 BCE). The name Unani reflects its Hellenistic origin and is derived from the Yunan, the ancient name of Greece [17]. Unani medicine flourished to its zenith during medieval ages (500-1500 CE) in the Muslim world, mostly in the Arabian Peninsula, Persia, Egypt, Syria, ancient Mesopotamia and in and around. It is also referred to as Greco-Arabian medicine and Persian medicine in different parts of the world [18]. Unani medicine is based on the Hippocratic concepts of Mizaj (temperament) and Akhlat(humors) [17]. Famous scholars of Unani medicine include IbnSina (Latinized as Avicenna, 980-1035 CE), ZakariyaRazi (Latinized as Rhazes, 865-925 CE), IbnRushd (Latinized as Averroes, 1126-1198 CE), NajeebuddinSamerqandi (d 1222 CE) and many others [18]. Unani Medicine recognizes the influence of surroundings and ecological conditions on the state of health of human beings. Apart from treating disease conditions, Unani Medicine lays down great emphasis on the prevention of disease and promotion of existing health through principles of six essential factors (Asbabe- SittaZarooriyah) of life. It also lays down great emphasis on the maintenance of a proper ecological balance and on keeping air, water and food free from all possible pollution and pathogens. An eminent Unani physician Galen (129-200 CE) postulated that certain diseases caused by pollutants tend to be carried by wind and hence, do disseminate faster; these enter into human body through respiratory route. As per Unani classical wisdom, improving immunity with immune boosters is one of the key approaches for prevention of disease and maintenance of health [19].

Unani Medicine in Context of Infectious Diseases and Epidemics or Pandemics Situation (Waba)

The ‘germ theory of disease’ was established as late as 1683 CE with the development of the first microscope [20]. For obvious reasons, the concept of microbes as disease-causing agents does not find a direct reference in Unani medicine. However, there is an adequate understanding that certain ajsam-i-khabitha (literally translated as ‘bad substances’) can migrate from the diseased to healthy persons, and may cause diseases [21]. This theory of contagion is advocated by a number of Unani scholars. According to Jalinoos (Latinized as Galen, 131-199 CE), ‘a physician should always keep an eye on changes of weather and air [22]. A treatise of ZakariyaRazi (865-925 CE), Kitab fi al-jadari wa-al-hasbah (Book on Smallpox and Measles) describes the modes of spread of the two diseases and their differential diagnosis. In May 1970, it was regarded as “the first scientific treatise on the subject” by WHO[18]. According to IbnSina (980-1035 CE), air and water are contaminated only after admixture of ajsam-i-khabitha, which does not happen otherwise. He further states, such contamination can also be brought about if the dead bodies of people dying due to an epidemic are not disposed off properly [21]. It indicates that, he had knowledge of microbes being present in the body even after death, which could potentially infect others. During the 14th-century plague pandemic, Spanish scholar IbnKhatima (1364-1369 CE) mentioned in his treatise ‘Tahsilgaraḍal-qasid fitafsil al-maraḍ al wafid (succeeding in clarifying pest disease) that ‘I have observed that a person who comes in close contact with a patient of plague will start suffering from the same symptoms [23,24].

It is proved that ancient scholars of Unani medicine had excellent knowledge about disease transmission. A comprehensive literature search indicates that the term ‘Waba’ is used in Unani literature to describe epidemics and pandemics collectively for diseases which spread in a large geographical area. Avicenna already mention that epidemics supposed to occur when Ajsami- khabisa (contagion), find a place in air and water [25].

ZakariyaRazi (865-925 CE) statedin his book Kitab al- Mansoori(Book dedicated to Caliph Mansoor), most epidemics spread in the autumn season, especially if the preceding summer season was humid, and the wind is still. In this context, the direction of winds is given utmost significance.

Razi had absolute idea of quarantine; he stated transportation of public must be stopped during epidemic of plague and also advised the people should not together in crowding places when somebody has leprosy or epidemic fever because infection can be transferred to others. The fourth chapter of Al-Mansoori discuss about infectious diseases which are more common in rainy season and advised the public to take fruits particularly apple, grapes, pomegranate, barley water and lemon frequently for prevention of infectious diseases. The tenth chapter shortly described the management of smallpox and measles.

As IbnHubal Baghdadi(1121-1213 CE) mentioned in his treatise Kitab al-Mukhtarat-fil-Tib (The Book on Choice of Medicine), if southern winds are replaced by northern winds, then catarrhal illnesses will occur in abundance. Because, as stated by Razi in the 15th volume of his treatise Kitab al-Hawi (The Comprehensive Book of Medicine), southern winds are warmer while the northern winds are colder, and this change of temperature makes people more susceptible to respiratory infections.

Furthering the view, IbnSina (980-1035 CE) stated that epidemics spread from one person to other and one city to another ‘like a message’. ZakariyaRazi (865-925 CE) stressed this fact and stated that there will always be something common in patients of epidemics, whether a place, food, drink or travel history. During the 14th-century plague pandemic, Arabian scholar IbnKhatib (1313-1374 CE) stressed that ‘most of the people who come in contact with a plague victim will die. In the same context, he stated the disease spreads through clothes, utensils and jewellerythus stressing on transmission through fomites. In the same vein, this statement stresses on social distancing and isolation, two important aspects of prevention in the current pandemic [16]. The 13th-century’s Persian scholar Najeebuddin Samarqandi mentioned about a type of Nazla-e-Wabaiya(epidemic influenza) in his treatise Al-Asbab wa-Alamat (the book of causes and symptoms). In the translated version of the book, published by the name of Sharah Asbab, the disease is mentioned by the name of Nazla-e-Wabaiya(epidemic influenza) in the chapter on Anaf al-Anza (Influenza)and Humma Wabaiya (epidemic fever) characterized by fever, sneezing, sore throat, nasal irritation and malaise and may also suffer from cough, diarrhea, and delirium. Pleurisy and pneumonia, if present, worsens the prognosis [25]. Specifically, weakness sets in early in the disease [16].

It is worthy important to mention here that Unani medicine does not mention epidemics and pandemics as separate entities, and a common term ‘Waba’ is used for those diseases which affect a large geographical area. This is probably for two reasons, first and foremost, global communication was not possible in medieval ages like today; and second, travel over very long distances would have rarely occurred, hence the occurrence of a pandemic would have been a remote possibility, practically unlikely [26].

Perception of Unani Medicine

As per Unani medicine exact term or disease for this pandemic case is not mentioned in Unani literature but it can be explained under the broad head of Humma-e-Wabaiya(Epidemic fever) andNazla-e-Wabaiya (epidemic influenza). The symptoms of Nazla Wabaiya and Humma Wabaiya mimic with the symptoms of COVID-19 [25].

Humma-e-Wabaiya is adevastating type of fever which occurs due to unavoidable changes in the Air (qualitatively or quantitatively). As a result Air becomes impure and finally it gives rise to abnormal temperament of Rooh (Sprit)which subsequently results into morbidity and mortality. As fresh and pure Air is essential for health, any contamination in the Air may affect the health of any person and it depends on the intensity of contamination. Mainly those people are susceptible who have a weak immune system i.e. older and children, accumulation of waste humours and widening of skin pores. Rabban Tabari (838-870 CE)stated that people who have excess waste material in their body are usually affected with Humma wabaiya [1]. The dominance of temperature exists in Humma-e-Wabaiya and in Nazla-e-wabaiyathe influence of catarrh symptoms present much than it.

Persons with a comorbid state or a weak constitution have been described by IbnSina as being more susceptible to epidemic diseases and having a poor prognosis [27]. Moreover, the importance of air purification, modes of transmission of infection and significance of quarantine/isolation has also been defined by Ibn Rushed in his book Kitab al-Kulliyat (Treatise on Principles of Unani Medicine) [28].

It is evident that despite the inability to observe microbes, Unanischolars could envision and comprehend their sources and reservoirs, modes of transmission of infections, and potential causes of infections turning into epidemics. The theories and observations closely resemble the contemporary knowledge of infections, which reinforce the fact that Unani medicine can play a significant role in combating current health problems [16].

Promising Measures to Prevent and Manage Covid-19 According to Unani Medicine

The above information let us indicates that the symptoms of Humma-e-Wabaiya and Nazla-e-Wabaiya are closely similar to Covid-19. And as per evidence of Unani medical manuscripts we can recommend the following possible measures to prevent and manage Covid-19. On the other hand in Unani system of Medicine there are a detailed description of drugs which shown antiviral and immuno-modulatory properties supported by scientific studies [19,29,30].

Prevention

Unani Medicine recognizes the influence of surroundings and ecological conditions on the state of health of human beings. Apart from treating disease conditions, Unani Medicine lays down great emphasis on the prevention of disease and promotion of existing health through principles of six essential factors (Asbabe- SittaZarooriyah) of life. It lays down great emphasis on the maintenance of a proper ecological balance and on keeping air, water and food free from all possible pollution and pathogens [31]. An eminent Unani physician Galen (129-200 CE) postulated that certain diseases caused by pollutants tend to be carried by wind and hence, do disseminate faster; these enter human body through respiratory route [32].

General measures of isolation, quarantine, and distancing must be followed for prevention of epidemic infection. Transmission through fomites is highly likely, so care should be taken in handling and disposing of the same. Health care workers, family members and caretakers of the patients should take due precautions. Stay in well-ventilated places reduces the chances of contracting the infection. Razi's advice of avoiding airflow from the patient to a healthy person is remarkable. For this purpose, the patient should face away from healthy people while coughing, sneezing or talking, as the virus may also be excreted through saliva. Sanitization of the environment should always be given special importance as it serves as the medium for lodging and dissemination of the virus. Several drugs have been prescribed for spray, for application on curtains, as sanitizers on the body, and for fumigation. These drugs are mostly aromatic [16].

In context to protect the health during the Waba (epidemics/ pandemics) situation, Unani scholars also emphasized on immuno-modulation, they were aware about the effect of the citrus fruits. They also suggested healthy diet, avoiding starvation, avoiding meat and fish, staying hydrated and certain drugs have also been prescribed for the promotion of health.

Management

Najeebuddin Samarqandi described in his treatise “Al-asbab wa- Alamat” (The book of causes and symptoms), translated version named as “Sharah Asbab” to manage this situation by antiinflammatory, immuno-modulatory and antipyretic drugs.

Here is the list of few unani drugs/herbs or medication described in classical text that are scientifically evaluated for its therapeutical properties that we can recommend for this epidemic scenario. Antiviral activity of the mentioned drugs against COVID-19 is not being claimed (Tables 1-3)[16,33-55].

Table 1 Drugs prescribed for sanitization of environment during epidemics.

Table 2 Drugs prescribed for the protection of health during epidemics.

Table 3 Drugs prescribed in Unani medicine for Nazla-e-wabaiya (epidemic influenza) /Humma -e-Wabaiya (epidemic fever).

Below mentioned Unani herbs have shown few leads to possess certain antiviral and Immunity Enhancingactivities on scientific study. Antiviral activity of the above-mentioned drugs against COVID-19 is not being claimed.

Antivirals

Kalonji(Nigella sativa) [56], Seer(Allium sativum) [57-61], Zanjabeel(Zingiberofficinale) [61-63], Aslassus(Glycyrrhizaglabra) [64-69], Afsanteen(Artemisia absinthium) [70,71], Tukhm-e- Kasoos(Cuscutareflexa) [72], Khayarshamber(Cassia fistula) [73,74], Gilo(Tinosporacordifolia) [75,76].

Immunity Enhancers

Khameera Marwareed [77] but Not recommended for diabetics, Asgandh (Safoof) [78-84].

Conclusion

The aim of this paper is to focus on the Perception of epidemic diseases in Unani medicine and possible role for prevention and treatment of COVID19. Concepts of sanitation, isolation, air purification and immune-modulation described in Unani medicine remain the basic tenets of infection containment in the contemporary preventive medicine.

This may also encourage the researchers to conduct the scientific studies on the prophylactic clinical trials by boosting the immunity and trials on therapeutical effectiveness of Unani drugs in COVID-19 patients. As Herbal medicines have several bioactive compounds such as phenols, vitamins, several antioxidants, etc. with important pharmacological activity, hence they can play a significant role in reducing the disease burden in the contemporary world.

The Holistic approach of Unani medicine gives focus on prevention through life style modification which can be achieved by keeping balance in Asbabsittazarooria, dietary management, prophylactic drugs to boost the immunity and some other medicines based on the presentation of the symptoms of the disease. Therefore, in case of pandemic situation the above factual deliberation suggests the Importance of Unani drugs as well as preventive measures which have been used for several decades in the treatment of various illnesses which are similar to covid-19.

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