Guidelines for safer panchakarma practice in non-covid clinical care during corona pandemic.

Morbidity and mortality statistical trends of COVID-19 pandemic reveal that, "The coronavirus may be with us for a long time, and we have to learn to live with it rather than hope to vanquish its threat". Considering these trends, it is imperative to make changes in our lives at home and workplace so as to prepare ourselves to face and protect the community at large from the risk of infection. Human interaction is necessary in healthcare particularly in panchakarma due to which panchakarma practitioners are in a dilemma about how to start their services in the non-covid cases and how to protect the patients and hospital personnel from the possibility of exposure to COVID-19 infection. With this background, preliminary guidelines have been formulated as an aid to resume the panchakarma procedures. This guideline highlights the specific measures needed to protect occupational safety and quality in healthcare services in the area of panchakarma practice amid the COVID-19 pandemic.

Introduction

Currently, the world is facing a dual burden of diseases – one is non-communicable diseases such as diabetes mellitus, hypertension, chronic obstructive pulmonary disease etc., while the other one is of novel communicable diseases such as SARS-CoV, SARS-CoV2, Zika, Ebola, Nipah virus etc. It is a known fact that Ayurveda, particularly, panchakarma has a definitive role in the management of chronic non-communicable diseases [1].

Panchakarma is an important and unique specialty of Ayurveda; basically it is a bio-cleansing regimen (shodhana karma) intended to eliminate the disease causing toxic elements from the body thereby maintaining the homoeostasis of doshas. It is applied in deep-rooted chronic diseases as well as seasonal abnormal imbalance of Tridoshas [2]. The panchakarma department in any Ayurveda hospital is an important clinical unit, as it offers services to many patients referred from different clinical departments of the hospital, performs the procedures as advised by the treating physician and after completion of the therapy, sends back the patient to the treating doctor.

Need for the guidelines

Morbidity and mortality statistical trends of COVID-19 pandemic reveal that, “The coronavirus may be with us for a long time, and we have to learn to live with it rather than hope to vanquish its threat” [3]. Hence, we should make changes in our lives at home and workplace so as to be prepared to face and protect the community at large from the risk of infection.

Ongoing uncertain situation of COVID-19 reminds us about the basic premise of the management i.e. 'prevention is better than cure', because viral diseases are hard to cure and once contacted, they can be life-threatening. Considering the gravity of the corona pandemic, it is apt to say that prevention is the only and ultimate measure to contain the spread of COVD- 19.

Since the day of Janta curfew on March 22, 2020 in India [4], all the activities related to panchakarma in various health centres and hospitals across India have been shutdown till date. However, its time to resume activities related to panchakarma since the lockdown rules and relaxations in the public movement have been eased. Human interaction is necessary in healthcare particularly in panchakarma; however, panchakarma practitioners are in a dilemma about how to start their services in the non-covid cases and how to protect the patients and hospital personnel from the possibility of exposure to COVID-19 infection. With this background, preliminary guidelines have been formulated as an aid to resume the panchakarma procedures.

These guidelines highlight the specific measures needed to prevent nosocomial COVID-19 infections, and to protect occupational safety and quality in healthcare services in the area of panchakarma practice amid the corona pandemic.

Panchakarma siddhi ashtakam (eight aspects of panchakarma practice)

The word ‘siddhi’ implies successful administration of panchakarma in non-COVID cases during the ongoing pandemic without getting infected with the infection. The word ‘ashtakam’ implies eight aspects which are related to panchakarma practice. Panchakarma siddhi ashtakam are depicted in Fig. 1. Specific guidelines have been detailed with respect to these eight aspects -

Fig. 1

Panchakarma siddhi ashtakam.

Panchakarma kaksha (theatre)

Daily sanitization of the panchakarma theatre with sodium hypochlorite solution [5] as per the standard practices. Sodium hypochlorite, commonly known as bleach, is most frequently used as a disinfecting agent. It is a broad-spectrum disinfectant that is effective for the disinfection of viruses, bacteria, fungi, and mycobacterium [6].

Dhupana karma – this medicated fumigation may be continued throughout the corona pandemic. Aparajitha Dhoopa choornam fumigation prevents the spread of infectious fever and also disinfects the air from pathogens. The antimicrobial activity of Aparajitha Dhoopa choornam has also been established [7].

Lighting of ghee lamps – It purifies indoor environment due to its visha grahadi bhutaghnam effect or you may use beewax candles (bhutaghnam). This can be practiced on regular basis especially during the pandemic.

Display the infographics related to prevention and protection from COVID-19 inside and outside the theatre.

Information related to techniques of hand-washing should be displayed at every point of hand-washing.

Floor of the panchakarma theatre should be cleaned with antimicrobial liquid after attending every patient of panchakarma.

Washrooms attached to the theatre and common facility area should be cleaned and sanitized after every use, irrespective of by the patients or staff, so as to avoid the transmission of corona from urine and faeces [8].

Common facility areas of high-touch surfaces related to panchakarma should be cleaned frequently.

Doorknobs and handles may be coated with ‘copper foil’ or doors may be fitted with ‘foot-operated door opener’ wherever possible so as to avoid contamination due to frequent touching.

Panchakarma upakaran (equipment and other utensils)

Automated panchakarma equipment is an ideal choice during COVID-19 pandemic so as to maintain physical distancing to a maximum extent.

Droni should be cleaned with herbal liquid soap or herbal handwash liquid after attending every patient.

Copper utensils are advisable for the use in panchakarma.

Disposable paper cups may be made available for drinking water.

Use of dustbins having the proper lid.

Panchakarma dravya (medicines)

Panchakarma medicines which are being used successively for 3–7 days in the case of shirodhara, sarvangadhara etc. should be properly covered to reduce any chance of contamination.

Medicines preparation area (kitchen) should also be sanitized and cleaned regularly and frequently.

Panchakarma Vaidya (specialist)

Physician must and should obtain written and signed consent from patient [9] for whom you have advised panchakarma that, he/she or their family members have never tested positive for COVID-19, his/her residential area has never been declared as containment zone (supported with aadhar address proof), he/she will report whenever patient suffers from fever or any other typical or atypical symptoms of COVID-19 and assurance from the patient he/she will not participate in any gathering of more than five people.

Panchakarma specialist must follow social distancing and masking to prevent transmission to/acquiring infection from other healthcare workers who may be asymptomatic carrier.

Physician whosever falls under vulnerable criteria i.e, aged above 65 years or having co-morbidities such as hypertension, diabetes mellitus, chronic kidney disease, cancer, etc., should take extra precautions while attending panchakarma patients.

Personal protective equipment (PPE) - Single-use hand-gloves for each patient, medical mask, face-shield, disposable head-cover, shoe-cover and washable gowns as required should be available.

Basic information and any updates related to prevention and protection from COVID-19 should be informed to technicians and patients. If possible encourage the technicians to undergo online training on infection prevention and control available on iGOT platform [10].

Panchakarma paricharak (technicians)

Technicians must use mask and appropriate PPE at all times while on duty.

Health Care Workers (HCW) after leaving the patient-care units (wards/OPDs/IPDs) at the doctor's duty rooms/hostels/canteen or outside the healthcare facility must follow social distancing and masking to prevent transmission to/acquiring infection from other HCWs who may be asymptomatic positive.

Ensure that all preventive measures like frequent washing of hands/use of alcohol-based Ayurvedic hand sanitizer, respiratory etiquettes (using tissue/handkerchief while coughing or sneezing), etc. are followed at all times.

It is advisable that one patient is attended by one technician during the COVID-19 pandemic.

Rogi (patients)

Patient education about COVID-19 is very important.

Personal conveyance to commute between hospital and home for panchakarma therapy is more advisable.

Patients who have contact history, positive history and living in COVID-19 containment zones should not be considered for panchakarma.

Using mask and physical distancing among the patients is must.

Hand hygiene and respiratory hygiene practices at all times are very essential

Better avoid panchakarma to patients belonging to vulnerable group i.e, aged above 65 years or less than 10 years or having co-morbidities such as hypertension, diabetes mellitus, chronic kidney disease, cancer, etc. However, if advised as necessary, it is important to take extra care while performing panchakarma.

Advise patients to come for panchakarma with bare minimum or no belongings and attendants.

Patients may be served with ‘Ayush kwath tea’ [11] after completion of panchakarma therapy.

Latest COVID-19 RT-PCR testing (one week before the therapy) should be mandatory for the patient for whom panchakarma is planned. Make sure that the patient is negative before initiation of the therapy.

Panchakarma prakriya (procedures)

It is advisable to avoid the therapies which involve upper part of the body such as vamana karma, nasya karma, karna poorana etc. However, if physician feels it is necessary then, N95 mask, face shield, disposable gowns, PPE gloves are necessary to be worn by the physician and staff involved in the process.

Procedure-wise standard operating practices released by Ministry of AYUSH in the month of January 2021 should be followed during the pandemic while perfoming panchakarma [12].

Instead of going for classical panchakarma during the pandemic, it may be advisable to go for ‘sadyo karma’ such as sadyovamana, sadyovirechana, matravasti etc after assessing the risk-benefit ratio.

It is advisable to use single-use disposable items for the therapies.

While planning and administering panchakarma therapy, it is wise to remember the case definition of a contact is “any person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a probable or confirmed case: i. Face-to-face contact with a probable or confirmed case within 1 month and for more than 15 min; ii. Direct physical contact with a probable or confirmed case and iii. Direct care for a patient with probable or confirmed COVID-19 disease without using proper PPE [13].

It is more sensible to handle one case at one time.

Panchakarma apashisht prabandhan (waste management)

Wastes generated out of panchakarma procedures such as oils, liquids, cotton, hand-gloves, mask, loin clothes, disposable undergarments, empty medicine containers, bottles etc. should be properly disposed as per the latest guidelines and amendments of biomedical waste management rules [14].

The general guidelines which may be employed during panchakarma practice are:

It is advisable for all the healthcare staff and patients to download and install ArogyasetuApp [15] and AYUSH SanjivaniApp [16] and to follow the Ayurvedic IBM (Immunity Boosting Measures) as advised by Ministry of AYUSH [17].

Anu tailam for intranasal application (pratimarsha nasya) should be practiced by all including patients, regularly while leaving home for hospital.

Regular thermal screening by using ‘Non-contact digital Infrared forehead thermometers’ (NCIT) [18] should be done for all hospital staff and patients while entering the hospital.

Foot-operated sanitizer dispenser stand or touchless wall-mounted sanitizer dispenser is an ideal option to be placed at the entry of the hospital.

It is essential to follow WHO's “Five Moments for Hand Hygiene” before touching a patient, before any clean or aseptic procedure, after exposure to body fluid, after touching a patient, and after touching a patient's surroundings [19]. Staff must be trained by the physician for the hand-washing techniques recommended by WHO [20].

‘The 7 Musts’ for safer workplaces viz., wearing reusable face cover, maintaining physical distance, practicing hand hygiene and cleaning surfaces, avoiding spitting in the open, avoiding mass gatherings, being empathetic and self monitoring your health should be be followed [21].

If every staff of the panchakarma hospital/centre including doctor are found negative on COVID-19 testing, you may display a board at the entry point as “COVID-19 safe zone”. If possible repeat the testing every week.

Any directions from Government of India or local authorities regarding COVID-19 pandemic which may directly or indirectly influence the panchakarma practice should be complied with.

These guidelines may be followed till the pandemic persists.

While panchakarma is important to cleanse and eliminate disease-causing toxic elements from the body, it is important to follow safety guidelines while performing the same. The above-mentioned guidelines may be adopted by panchakarma hospitals/centres to prevent COVID-19 infection among the patients and HCWs amid the ongoing pandemic.

Source(s) of funding

None.

Conflict of interest

None.