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• 1 •
Chin J Integr Med
In December 2019, a pneumonia associated
with the corona virus disease 2019 (COVID-19)
emerged in Wuhan, Hubei Province, China.(1) It is
highly contagious and has quickly spread to many other
parts of China and some other countries within 1 month
since the fi rst report emerged. As of February 11, 2020,
44,653 cases of confi rmed infections and 1,113 deaths
have been reported in Chinese mainland.(2) Outside
of China, there had been 395 confirmed cases and 1
death from 24 countries were reported as of February
11, 2020.(3) The outbreak of COVID-19 raised intense
attention not only within China but internationally.(4) On
20 January 2020, the Chinese government added it to
the Notifiable Communicable Disease List and gave
the highest priority to its prevention and treatment.(5)
On 30 January 2020, the World Health Organization
©The Chinese Journal of Integrated Traditional and Western
Medicine Press and Springer-Verlag GmbH Germany, part of
Springer Nature 2020
Supported by the National Natural Science Foundation of China
(No.81830115), China; Prof. Nicola Robinson (visiting professor
of Beijing University of Chinese Medicine) is supported by the
Overseas Expertise Project, Ministry of Education of China (No.
MS20080009)
1. Institute for Tibetan Medicine, China Tibetology Research
Center, Beijing (100101), China; 2. Centre for Evidence-Based
Chinese Medicine, Beijing University of Chinese Medicine,
Beijing (100029), China; 3. School of Traditional Chinese
Medicine, Beijing University of Chinese Medicine, Beijing
(100029), China; 4. School of Health and Social Care, London
South Bank University, London (SE1 0AA), UK; 5. Institute of
Integrated Traditional Chinese Medicine and Western Medicine,
Guangzhou Medical University, Guangzhou (510120), China
Correspondence to: Prof. LIU Jian-ping, E-mail: jianping_l@
hotmail.com
DOI: https://doi.org/10.1007/s11655-020-3192-6
ABSTRACT
ABSTRACT
Objective
Objective
: Since December 2019, an outbreak of corona virus disease 2019 (COVID-19) occurred in
: Since December 2019, an outbreak of corona virus disease 2019 (COVID-19) occurred in
Wuhan, and rapidly spread to almost all parts of China. This was followed by prevention programs recommending
Wuhan, and rapidly spread to almost all parts of China. This was followed by prevention programs recommending
Chinese medicine (CM) for the prevention. In order to provide evidence for CM recommendations, we reviewed
Chinese medicine (CM) for the prevention. In order to provide evidence for CM recommendations, we reviewed
ancient classics and human studies.
ancient classics and human studies.
Methods
Methods
: Historical records on prevention and treatment of infections in
: Historical records on prevention and treatment of infections in
CM classics, clinical evidence of CM on the prevention of severe acute respiratory syndrome (SARS) and H1N1
CM classics, clinical evidence of CM on the prevention of severe acute respiratory syndrome (SARS) and H1N1
infl uenza, and CM prevention programs issued by health authorities in China since the COVID-19 outbreak were
infl uenza, and CM prevention programs issued by health authorities in China since the COVID-19 outbreak were
retrieved from different databases and websites till 12 February, 2020. Research evidence included data from
retrieved from different databases and websites till 12 February, 2020. Research evidence included data from
clinical trials, cohort or other population studies using CM for preventing contagious respiratory virus diseases.
clinical trials, cohort or other population studies using CM for preventing contagious respiratory virus diseases.
Results
Results
: The use of CM to prevent epidemics of infectious diseases was traced back to ancient Chinese practice
: The use of CM to prevent epidemics of infectious diseases was traced back to ancient Chinese practice
cited in
cited in
Huangdi's Internal Classic
Huangdi's Internal Classic
(Huang Di Nei Jing) where preventive effects were recorded. There were 3
(Huang Di Nei Jing) where preventive effects were recorded. There were 3
studies using CM for prevention of SARS and 4 studies for H1N1 infl uenza. None of the participants who took CM
studies using CM for prevention of SARS and 4 studies for H1N1 infl uenza. None of the participants who took CM
contracted SARS in the 3 studies. The infection rate of H1N1 infl uenza in the CM group was signifi cantly lower than
contracted SARS in the 3 studies. The infection rate of H1N1 infl uenza in the CM group was signifi cantly lower than
the non-CM group (relative risk 0.36, 95% confi dence interval 0.24–0.52;
the non-CM group (relative risk 0.36, 95% confi dence interval 0.24–0.52;
n
=4). For prevention of COVID-19, 23
=4). For prevention of COVID-19, 23
provinces in China issued CM programs. The main principles of CM use were to tonify qi to protect from external
provinces in China issued CM programs. The main principles of CM use were to tonify qi to protect from external
pathogens, disperse wind and discharge heat, and resolve dampness. The most frequently used herbs included
pathogens, disperse wind and discharge heat, and resolve dampness. The most frequently used herbs included
Radix astragali
Radix astragali
(Huangqi),
(Huangqi),
Radix glycyrrhizae
Radix glycyrrhizae
(Gancao),
(Gancao),
Radix saposhnikoviae
Radix saposhnikoviae
(Fangfeng),
(Fangfeng),
Rhizoma Atractylodis
Rhizoma Atractylodis
Macrocephalae
Macrocephalae
(Baizhu),
(Baizhu),
Lonicerae Japonicae Flos
Lonicerae Japonicae Flos
(Jinyinhua), and
(Jinyinhua), and
Fructus forsythia
Fructus forsythia
(Lianqiao).
(Lianqiao).
Conclusions
Conclusions
:
:
Based on historical records and human evidence of SARS and H1N1 influenza prevention, Chinese herbal
Based on historical records and human evidence of SARS and H1N1 influenza prevention, Chinese herbal
formula could be an alternative approach for prevention of COVID-19 in high-risk population. Prospective, rigorous
formula could be an alternative approach for prevention of COVID-19 in high-risk population. Prospective, rigorous
population studies are warranted to confi rm the potential preventive effect of CM.
population studies are warranted to confi rm the potential preventive effect of CM.
KEYWORDS
KEYWORDS
Chinese medicine, corona virus disease 2019 (COVID-19), prevention program, clinical evidence,
Chinese medicine, corona virus disease 2019 (COVID-19), prevention program, clinical evidence,
review
review
LUO Hui1,2, TANG Qiao-ling3, SHANG Ya-xi2,3, LIANG Shi-bing2,3,
YANG Ming2,3, Nicola Robinson2,4, and LIU Jian-ping2,5
Available online at link.springer.com/journal/11655
Journal homepage: www.cjim.cn/zxyjhen/zxyjhen/ch/index.aspx
E-mail: cjim_en@cjim.cn
hinese Journal of Integrative Medicine
C
Hot Topic
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
• 2 • Chin J Integr Med
(WHO) declared a public health emergency of
international concern for China's COVID-19.
Although the WHO said: "To date, there is no
specifi c medicine recommended to prevent or treat the
novel coronavirus",(6) in China, historically, when the
outbreak started, Chinese medicine (CM) approaches
including oral administration of preventive herbal
formulae, wearing CM sachets, indoor herbal medicine
fumigation, etc. were recommended for prevention and
treatment.(7,8) For example, in 2003, CM approaches
were used to prevent and treat severe acute respiratory
syndrome (SARS),(9,10) which was the most serious
infectious disease outbreak in China prior to the
COVID-19. In 2009, during the pandemic of H1N1
infl uenza around the world, the National Administration
of Traditional Chinese Medicine of China issued a CM
prevention program, which included 4 Chinese herbal
medicine (CHM) formulae for adults of different CM
body constitutions and one for children.(11) The current
outbreak of COVID-19 resulted in many provinces in
China issuing CM prevention and control programs,
among which the prevention programs are mainly oral
CHM formulae. This study has reviewed the historical
and human research evidence on CM in preventing and
control of infections in order to provide guidance for the
prevention of COVID-19.
METHODS
Data Sources
Three types of data were searched, including
historical classics records, human research evidence
and current prevention programs. (Ⅰ) Historical
classics records: records on the prevention of
epidemic diseases in ancient CM books were
searched, including history, treatment principles,
medicines and application of CM to prevent epidemic
disease. (Ⅱ) Human research studies: studies to
evaluate the preventive effects of CM on contagious
respiratory virus diseases were included. The inclusion
criteria were as follows. (1) Study design: clinical
trials, cohort studies, and other population studies
without control. (2) Population: high-risk populations
exposed to SARS or H1N1 infl uenza. (3) Intervention:
oral CHM formulae, including decoction, granules,
or patent medicine. (4) Control: placebo, blank or
without control group. (5) Outcome: infection rate
defi ned as laboratory-confi rmed incidence of disease.
(Ⅲ) Current prevention programs: CM prevention
programs for COVID-19 issued by the state or
provincial health authorities in China. Considering that
some provinces had regularly updated the programs
according to the local prevalence and clinical practice,
the most recent versions of the programs were
included for analyses in this study.
Literature Search
Retrieval strategy differed among the above
three types of data. The fi rst type of data was based
on mainly manual retrieval of ancient books of CM
on epidemic diseases, supplemented by electronic
database retrieval. The list of literature retrieved
was determined by discussion among all authors.
Secondly, 6 databases were searched including
PubMed, Google Scholar, the Cochrane Library,
China National Knowledge Infrastructure (CNKI),
Wanfang Data, and CQVIP database, with the key
words of "severe acute respiratory syndrome" (or
"SARS"), "infl uenza", "H1N1", "prevent*" and "Chinese
medicine" (pinyin: zhongyi or zhongyao). Thirdly,
government websites or offi cial media websites were
searched for prevention programs on COVID-19. Two
authors (Luo H and Tang QL) conducted the literature
search independently. The search date was up to
February 10, 2020.
Data Extraction and Analysis
The following data were extracted and analyzed:
source of evidence, time of publication or release,
author, setting, basis for formulation of CM prevention
strategy, composition of CM prescription, target
disease, course of prevention, effect, and adverse
reaction. The data was qualitatively described
and presented, and if possible, quantitative or
descriptive statistics were conducted. When the
data were available for pooling, meta-analysis would
be conducted by RevMan 5.3 software (https://
community.cochrane.org/help/tools-and-software/
revman-5/revman-5-download).
RESULTS
CHM Formula for Preventing "Pestilence" in
Ancient CM Classics
The theory of prevention and treatment of
"pestilence" (refers to fatal epidemic disease, pinyin:
wenyi) in CM originated from
Huangdi's Internal
Classic
(Huang Di Nei Jing), which was written
about 2000 years ago.(12) It suggested two aspects
which should be employed to prevent the spread of
epidemics. One was to maintain and improve the
• 3 •
Chin J Integr Med
healthy qi in the body by taking preventive medicine
[Xiaojin Dan (小金丹) in
Huangdi's Internal Classic
,
the first recommended formula of CM to prevent
pestilence], healthy diet care, exercise and so on, so
as to resist the invasion of external pathogen, and the
other was to avoid the source of infection.(13) These
two principles of epidemic disease prevention have
been followed by CM practitioners till now.(12,14)
Since
Huangdi's Internal Classic
, a large number
of formulae for preventing epidemic diseases have
been recorded in other ancient CM classics, such
as, the
Handbook of Prescriptions for Emergencies
(Zhou Hou Bei Ji Fang),
Essential Prescriptions Worth
a Thousand Gold for Emergencies
(Bei Ji Qian Jin
Yao Fang),
Medical Secrets of an Official
(Wai Tai
Mi Yao),
Compendium of Materia Medica
(Ben Cao
Gang Mu), etc.(15) The famous doctor SUN Si-miao
(541–682 AD) expounded the basis of medicines to
prevent "pestilence" in his book
Essential Prescriptions
Worth a Thousand Gold for Emergencies
: "pestilence
comes from nature, so to prevent it, we need to fi nd
medicinal herbs that also come from nature. People
would not be infected if they know and take preventive
medicine."(16) A literature study compared the
characteristics of medicinal formulae for preventing
pestilence in different periods of ancient China, found
that during the Jin and Tang Dynasties (3rd–10th
century AD), medicinal formulae were mainly used to
eliminate the pathogenic factors, while Ming and Qing
dynasties (14–20th century AD) focused on fortifying
Spleen (Pi), resolving dampness, clearing heat, and
detoxifying.(17)
Although many formulae for pestilence
prevention were recorded in ancient CM books,
the case description of prevention was relatively
rare. Through limited literature searches, we found
an interesting case report: SU Shi (1037-1101
AD), a famous poet in the Northern Song Dynasty,
accidentally found a formula for preventing pestilence
named Sheng San Zi (圣散子), a powder consisting
of 22 herbs.(18) Later, when he was demoted to
Huangzhou, Hubei Province, the pestilence had
been outbreak for several years. He disclosed the
prescription to the local people. After taking this
formula, the number of patients with the disease was
significantly reduced, and many lives were saved.
This story was recorded by SU Shi himself, when he
wrote a preface to his doctor friend PANG An-shi's
book
General Treatise on Febrile Diseases
(Shang
Han Zong Bing Lun).(18)
Evidence of CHM Formula for Preventing SARS
Three studies were identified including 1
controlled study(19) and 2 single cohort studies(20,21)
conducted during the epidemic of SARS.
Lau, et al(19) designed a controlled study to
evaluate a herbal formula for prevention of SARS (no
herbal intervention in the control group) and conducted
it in Hong Kong SAR, China. The sample size was
16,437 (1,063 in the herbal group and 15,374 in the
non-herbal group), and all participants were hospital
care workers including doctors, nurses, and other
staff. The result showed that none of the participants
who took modifi ed formula of Yupingfeng Powder (玉
屏风散) plus Sangju Decoction (桑菊饮) contracted
SARS, while 64 out of 15,347 (0.4%) in the non-herbal
group were infected with SARS (
P
=0.035). Nineteen
cases (1.8%) appeared minor adverse effects after 14
days taking herbal medicine, including diarrhea, sore
throat, dizziness, and nausea.
Both single cohort studies were conducted in
Beijing, China with sample sizes of 3,561(21) and 163,
respectively. All participants were medical staff from
two hospitals, where SARS patients were recruited
and treated during the study period. Among them, Xu,
et al's study(20) only included fi rst-line medical staff in
treating SARS. The courses of taking herbal formulae
for prevention were 6 days(20) and 12–25 days,(21)
respectively. The formulae used in these studies
were both classical formula Yupingfeng Powder plus
some heat-clearing and detoxifying herbs. The results
showed that none of the participants who took the
preventive herbal medicine had contracted SARS in
the two studies. Information on the safety of the herbal
medicines was not reported.
The details of the preventive herbal formulae of
the three studies are presented in Table 1.
Evidence of CHM Formula for Preventing H1N1
Infl uenza
Four studies were identified, including 3(22-24)
randomized controlled trials (RCTs) and 1(25) non-
randomized controlled clinical study. All the studies were
conducted during the prevalence of H1N1 influenza
in Chinese mainland and published in Chinese. In
• 4 • Chin J Integr Med
these studies, participants were exposed to high-risk
environments, such as hospitals and schools where
H1N1 influenza occurred. The total sample size was
25,636 with the largest one of 25,329.(25) The tested
herbal interventions included self-made herbal formulae
and Chinese patent medicines [Qingjie Fanggan Granule
(清解防感颗粒), Kangbingdu Oral Liquid (抗病毒口服液);
Ganmao Qingre Granule (感冒清热胶囊)]; while in the
control group, 1 study used placebo and 3 used blank
control. The course of herbal formulae ranged from 3 to 7
days, while the follow-up ranged from 5 to 30 days. The
outcome measure was infection rate of H1N1 infl uenza
tested by laboratory serological diagnosis. One study
reported that no adverse events occurred,(22) while the
others did not report. The details of the characteristics of
included trials are presented in Table 2.
The data on infection rate of H1N1 influenza
from 4 studies were pooled in meta-analysis. The
results showed that the infection rate in the herbal
formulae group was signifi cantly lower than that in the
control group [relative risk (RR) 0.36, 95% confi dence
Interval (CI) 0.24–0.52,
P
<0.01]. A sensitivity analysis
was conducted to exclude non-RCT and the results
showed similar effect (RR 0.36, 95% CI 0.21–0.62,
P
<0.01, Figure 1).
Summary of Officially Issued CM Prevention
Recommendations for COVID-19
Up to February 12, 2020, the National Health
Commission of China has issued 5 versions of
diagnosis and treatment programs for COVID-19, but
none have included any content on CM prevention and
control, but on treatment since the 3rd versions.(26)
Table 1. Ingredients of Herbal Formulae for
Preventing SARS
Study Latin name Pinyin Chinese
name
Lau JT 2005(19)
Folium mori
Sangye 桑叶
Flos chrysanthemi
Juhua 菊花
Semen armeniacae
amarum
Xingren 杏仁
Fructus forsythia
Lianqiao 连翘
Herba menthae
Bohe 薄荷
Radix platycodonis
Jiegeng 桔梗
Radix glycyrrhizae
Gancao 甘草
Rhizoma phragmitis
Lugen 芦根
Radix astragali
Huangqi 黄芪
Radix saposhnikoviae
Fangfeng 防风
Folium isatidis
Banlangen 板蓝根
Radix scutellariae
Huangqin 黄芩
Xu JY 2006(20)
Lonicerae Japonicae Flos
Jinyinhua 金银花
Radix astragali
Huangqi 黄芪
Rhizoma Atractylodis
Macrocephalae
Baizhu 白术
Radix saposhnikoviae
Fangfeng 防风
Glehniae Radix
Shashen 沙参
Crystal sugar Bingtang 冰糖
Zhang L 2005(21)
Radix astragali
Huangqi 黄芪
Rhizoma Atractylodis
Macrocephalae
Baizhu 白术
Radix saposhnikoviae
Fangfeng 防风
Cyrtomium fortune
J. Sm. Guanzhong 贯众
Isatidis Folium
Daqingye 大青叶
Radix Scutellariae
Huangqin 黄芩
Talcum
Huashi 滑石
Radix glycyrrhizae
Gancao 甘草
Table 2. Characteristics of Included Trials of Herbal Formulae for H1N1 Infl uenza
Study Design
type Population Average age
(Year)
Sample size
(Case, P/C)
Herbal
intervention Control Course
(d)
Follow
up (d) Outcome
Song YP
2019(22) RCT Population in close
contact with H1N1
infl uenza patients;
high-risk population
P: 25.6±14.2
C: 27.1±14.5
200 (100/100) Qingjie Fanggan
Granule
Placebo 3 30 Infection rate;
adverse event
Liu L
2013(23) RCT Medical staff P: 30.5±5.3
C: 31.4±4.7
3 (28/25) Decoction of self-
made formula 1Blank 7 10 Infection rate
Xia BL
2010(24) RCT Population in close
contact with H1N1
infl uenza patients
23.5 (18–26) 54 (27/27) Kangbingdu Oral
Liquid; Ganmao
Qingre Granule
Blank 3 14 Infection rate
Liu BL
2010(25) CCT Student Not report 25329 (23947/1382) Decoction of self-
made formula 2Blank 5 5 Infection rate
Notes: RCT: randomized controlled trial; CCT: controlled clinical trial; C: control group; P: prevention group. Ingredients of
formulae: 1
Arnebiae Radix
(Zicao),
Herba Menthae
(Bohe), and
Radix Glycyrrhizae
(Gancao). 2
Cyrtomium Fortune
J. Sm (Guanzhong),
Lonicerae Japonicae Flos
(Jinyinhua),
Fructus Forsythiae
(Lianqiao),
Folium Isatidis
(Banlangen),
Fructus Arctii
(Niubangzi),
Herba
Agastaches
(Huoxiang),
Lophatheri Herba
(Zhuye),
Radix Glycyrrhizae
(Gancao), and
Isatidis Folium
(Daqingye).
• 5 •
Chin J Integr Med
Of the 31 provinces (including autonomous
regions, and municipalities) in Chinese mainland,
health authorities in 23 provinces had offi cially issued
programs recommending herbal formulae to preventing
COVID-19. These 23 provinces cover 7 regions of
mainland: Northeast, North, Central (including Wuhan,
Hubei Province, the original outbreak of COVID-19),
South, East, Northwest, and Southwest China. All
programs were formulated by clinical experts organized
by local health authorities according to local geographic
and climate characteristics and COVID-19 prevalent
conditions. The earliest program recommending CM
for prevention was issued by Sichuan Province on
January 21, 2019. Ten provinces have updated their
programs since the fi rst announcement, 7 of them have
issued the 2nd edition and 3 issued the third edition.
The applicable population of preventive programs
included general and special population (such as the
elderly, children, pregnant women, patients with chronic
comorbidity diseases). Different groups of populations
had specifi ed preventive CM formulae. The programs
issued by the 23 provinces included CM formulae
ranging from 1 up to 10, with an average of 3.4 per
program. With regard to the course of CM formulae for
prevention, 11 provinces recommended from 3 to 14
days, while 12 provinces did not mention. In addition,
Tibet Autonomous Region recommended Tibetan
medicine and Guizhou province recommended Miao
medicine formulae (one of the minority folk medicines).
The basic characteristics of 23 provincial programs are
shown in Appendix 1.
We counted the frequency of the herbs used
in CM formulae for prevention of general population
issued by the 23 provinces. The results showed that
these formulae contained 54 different herbs, of which
19 herbs with a frequency of use for 3 or more times
in preventive formulae for general population (Figure
2). The top two were
Radix astragali
(Huangqi) and
Glycyrrhizae Radix Et Rhizoma
(Gancao).
Figure 1. Meta-Analysis of Comparison between Chinese Medicine Prevention and
Control (Blank or Placebo) on Infection Rate of H1N1 Infl uenza
Herbal formulae Placebo/blank Risk Ratio Risk Ratio
Study or subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Herbal formulae
vs.
placebo/blank (RCT)
Liu L 2013 2 28 8 25 20.4% 0.22 [0.05, 0.95]
Song YP 2019 9 100 23 100 55.5% 0.39 [0.19, 0.80]
Xia BL 2010 4 27 10 27 24.1% 0.40 [0.14, 1.12]
Subtotal (95% CI) 155 152 100.0% 0.35 [0.21, 0.62]
Total events 15 41
Heterogeneity: Chi2=0.51, df=2 (
P
=0.78);
I
2=0%
Test for overall effect
Z
=3.69 (
P
=0.0002)
Herbal formulae
vs.
placebo/blank (RCT and CCT)
Liu BL 2010 104 23,947 17 1,382 43.7% 0.35 [0.21, 0.59]
Liu L 2013 2 28 8 25 11.5% 0.22 [0.05, 0.95]
Song YP 2019 9 100 23 100 31.3% 0.39 [0.19, 0.80]
Xia BL 2010 4 27 10 27 13.6% 0.40 [0.14, 1.12]
Subtotal (95% CI) 24,102 1,534 100.0% 0.36 [0.24, 0.52]
Total events 119 58
Heterogeneity: Chi2=0.51, df=3 (
P
=0.92);
I
2=0%
Test for overall effect
Z
=5.33 (
P
<0.00001) 0.01 0.1 10 100
Favours prevention Favours control
1
Figure 2. Frequency of Commonly Used Herbs in
Preventive Formulae for COVID-19
Radix astragali
(Huangqi)
Glycyrrhizae Radix Et Rhizoma
(Gancao)
Radix saposhnikoviae
(Fangfeng)
Rhizoma Atractylodis Macrocephalae
(Baizhu)
Lonicerae Japonicae Flos
(Jinyinhua)
Fructus forsythia
(Lianqiao)
Atractylodis Rhizoma (Cangzhu)
Radix platycodonis
(Jiegeng)
Pogostemonis Herba (Huoxiang)
Cyrtomium fortune
J. Sm. (Guanzhong)
Perillae Folium (Zisuye)
Rhizoma phragmitis
(Lugen)
Glehniae Radix
(Shashen)
Citri Reticulatae Pericarpium
(Chenpi)
Ophiopogonis Radix
(Maidong)
Eupatorii Herba
(Peilan)
Folium isatidis
(Banlangen)
Coicis Semen
(Yiyiren)
Folium mori
(Sangye)
Chinese herbs Frequency
16
16
13
12
12
9
8
8
7
7
6
5
5
5
5
4
3
3
3
0 2 4 6 8 1012141618
DISCUSSION
As a new emerging acute respiratory infectious
disease, COVID-19 lacks effective methods to control
and treat the infection. It is urgent and reasonable to
explore effective intervention strategies from traditional
• 6 • Chin J Integr Med
medicine for its prevention. This study examines the
historical records for infection prevention in CM, as
well as previous clinical evidence on CM prevention
for similar public health emergencies such as SARS
and H1N1 influenza. Recorded literature showed
that the use of CM to prevent epidemics of infectious
diseases can be traced back to ancient CM practice
over thousands of years, and its successful effects
were preliminarily substantiated by modern human
clinical researches when applied to SARS and H1N1
influenza epidemics suggesting that historical CM
experience is a worthwhile approach.
Based on the comprehensive analyses of the
prevention programs issued by 23 provinces since
the COVID-19 outbreak, we found that the main CM
principles in preventing COVID-19 were to tonify
qi to protect and provide defense from external
pathogens, disperse wind and discharge heat, and
resolve dampness with aroma. It was also similar to
the characteristics of CHM formulae for preventing
"pestilence" in ancient times and SARS in 2003.(17,19)
The 6 most commonly used herbs were
Astragali
Radix
(Huangqi),
Glycyrrhizae Radix Et Rhizoma
(Gancao),
Saposhnikoviae Radix
(Fangfeng),
Atractylodis Macrocephalae Rhizoma
(Baizhu),
Lonicerae Japonicae Flos
(Jinyinhua), and
Forsythiae
Fructus
(Lianqiao).
Astragali Radix
(Huangqi),
Saposhnikoviae Radix
(Fangfeng), and
Atractylodis
Macrocephalae Rhizoma
(Baizhu) are all ingredients
of a classical herbal formula Yupingfeng Powder,
for tonifying qi to protect from external pathogens.
In Lao, et al's controlled study(19) of CM formula for
preventing SARS, Yupingfeng Powder was also the
main ingredients. Some studies have confirmed that
Yupingfeng Powder has antiviral, anti-inflammatory
and immunoregulatory effects.(27,28)
Japonicae Flos
(Jinyinhua) and
Forsythiae Fructus
(Lianqiao) are
the core components of Yinqiao Powder, which is a
classical formula used to prevent and treat respiratory
infectious diseases in ancient.(29) An experimental
study found that the effect of Yinqiao Powder (银翘
散) in preventing and treating upper respiratory tract
infection could be explained by its antibacterial and
antiviral properties and improvement of the function
of upper respiratory mucosal immune system.(30) A
multicenter, large-scale, randomized trial found that
Yinqiao Powder plus another heat-clearing formula
could reduce time to fever resolution in patients with
the H1N1 infl uenza virus infection.(29)
At present, the National Health Commission of
China has not issued a CM prevention program for
COVID-19. The reasons may be, first, according to
the CM theory of three-factors concerned treatment
(Sanyin Zhiyi, 三因制宜), due to the differences
of individual, regional, and seasonal factors in the
occurrence and distribution of diseases, these factors
should be considered in prevention and treatment,(31,32)
and second, lack of solid evidence of CM formula
for COVID-19. By comparing and analyzing the
prevention programs issued by provincial levels, we
also found that there was slight regional difference in
the recommended herbal formulae and prescription
principles. For example, due to the dry climate in
northern China, there are additional one or two herbs
for nourishing yin in the formula, like
Glehniae Radix
(Shashen) and
Ophiopogonis Radix
(Maidong), while
in the south, due to the humid climate, aromatic herbs
with the function of resolving dampness and turbidity
are used in the formulae, like
Pogostemonis Herba
(Huoxiang) and
Eupatorii Herba
(Peilan).
Individual difference was also considered in
the prevention programs in some provinces. There
were two or more formulae recommended in 18
provinces' programs, which were applicable for
different populations, such as the elderly, children,
pregnant women, or patients with chronic comorbidity
diseases, population in close contact with COVID-19
patients, etc. In addition, 7 provinces or province-
level municipality (Beijing, Tianjin, Shanxi, Henan,
Hunan, Shandong, Yunnan) recommended formulae
according to the types of CM body constitutions of the
population. This tailored prevention strategy might
help to improve the preventive effect.
We suggest that the safety should also be paid
attention to when taking CHM formula to prevent
COVID-19, especially when they are used for long
period. The public should choose the prescriptions
under the guidance of CM doctors according to the
program issued by provincial health authorities, and
avoid taking the prescriptions or herbs with unknown
origin and without offi cially approval. It should also be
noted that the prevention advice for taking decoction
were not reported in the 12 provinces' program.
According to the programs of other provinces, it is
appropriate to take the decoction for 1 week.
Based on the consideration of health economics
• 7 •
Chin J Integr Med
and balance of risks and benefits, we do not
recommend that all people should take CHM to prevent
COVID-19. Due to the highly contagion,(33,34) high-risk
populations exposed to COVID-19 patients, including
medical personnel, family members, and other people
who are in close contact with COVID-19 patients, as
well as residents living in COVID-19 outbreak areas,
would probably benefit from taking CHM formulae
for prevention. These formulae recommended in the
prevention programs are easily available in pharmacies
and hospitals across the country.
There are some limitations within this study.
Firstly, historical records of using CM for "pestilence"
prevention were examined in the review, however, the
term "pestilence" might be a broad concept in ancient
CM books, including infectious diseases transmitted
through respiratory tract, digestive tract and other
ways, so it might not be completely representative of
the respiratory viral diseases especially the COVID-19.
Secondly, as there is no direct clinical evidence for the
prevention of the new emerging COVID-19, currently
reported researches were from previous literature on
the prevention of SARS and H1N1 influenza by CM
which can only be considered as indirect evidence to
refer to the current outbreak. Thirdly, the prevention
programs for preventing COVID-19 were issued
shortly after the outbreak, which were formulated by
CM experts based on their previous experience in the
prevention and treatment of similar diseases and their
initial understanding of the disease; therefore, the actual
effect of these programs needs to be verifi ed in clinical
application, and updated and improved according to the
evidence of new researches on COVID-19.
For future studies, we recommend prospective
cohort studies, RCTs or registry studies to evaluate the
effect of CHM formulae in prevention of COVID-19. At
present, as the COVID-19 has not yet been controlled,
we expect that a series of prospective population
studies with rigorous design and large sample should
commence with protocol registration, ethical approval, and
implementation in a timely manner, to produce reliable
evidence for CM prevention of COVID-19 or similar
emerging respiratory infectious diseases in the future.
In conclusion, based on historical records and
clinical evidence of SARS and H1N1 infl uenza prevention,
CHM formula could be an alternative approach for the
prevention of COVID-19 in high-risk population while
waiting for the development of a successful vaccine.
Prospective well design population studies are needed to
evaluate the preventive effect of CM.
Confl icts of Interest
The authors declare that they have no competing interest.
Author Contributions
Luo H, Tang QL, and Liu JP conceived of the design and
carried out the study. Tang QL undertook the literature review of
historical evidence and assisted in writing the manuscript. Shang
YX and Liang SB translated and assisted in analyzing Chinese
data. Yang M provided suggestions for the design of study. Luo
H undertook the literature review of prevention programs and
wrote the manuscript. Liu JP supervised the study and revised
the manuscript. Robinson N revised the manuscript and provided
important perspectives. All authors read and approved the fi nal
manuscript. Luo H and Tang QL contributed equally to this work.
Electronic Supplementary Material: Supplementary material
is available in the online version of this article at https://doi.
org/10.1007/s11655-020-3192-6.
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(Accepted February 13, 2020)
Edited by YUAN Lin
