S 0192415 X 20500500

The American Journal of Chinese Medicine, Vol. 48, No.
5, 1035–1049
© 2020 World Scientific Publishing Company
Institute for Advanced Research in Asian Science and Medicine
DOI: 10.1142/S0192415X20500500
Analysis of Traditional Chinese Medicine

by 182.1.221.207 on 10/23/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
Diagnosis and Treatment Strategies for

COVID-19 Based on “The Diagnosis and
Am. J. Chin. Med. 2020.48:1035-1049. Downloaded from www.worldscientific.com
Treatment Program for Coronavirus

Disease-2019” from Chinese Authority
Zhi-Hui Zhao,*,a Yi Zhou,†,a Wei-Hong Li,* Qing-Song Huang,†

Zhao-Hui Tang* and Han Li*
*Basic Medical College
Chengdu University of Traditional Chinese Medicine

Chengdu, Sichuan 611137, P. R. China
†
Hospital of Chengdu University of Traditional Chinese Medicine
Chengdu, Sichuan 610072, P. R. China
Published 1 July 2020
Abstract: In December 2019, coronavirus disease-2019 (COVID-19) broke out in Wuhan and
other places. Seven versions of the Diagnosis and Treatment Program for Coronavirus
Disease-2019 successively issued by the Chinese government have designated traditional
Chinese medicine (TCM) as a necessary medical strategy. Based on the changes in TCM
diagnosis and treatment strategies in these seven versions of Diagnosis and Treatment
Program for Coronavirus Disease-2019, this paper collected data reported by the Chinese
government media; analyzed the understanding of the etiology, pathogenesis, syndrome
differentiation, treatment methods, and prescriptions of COVID-19 by TCM and evaluated
the clinical efficacy of TCM strategies. COVID-19 is associated with TCM disease of pes-
tilence, and its pathogenesis can be summarized as an “epidemic pathogen invading the
body, followed by entering the internal organs and transforming into heat, resulting in
pathogen trapping in the interior and healthy qi collapsing, and deficiency of qi and yin”.
Pathological processes should be emphasized in syndrome differentiation. The manifesta-
tions of qi deficiency and yin deficiency are exhibited during the recovery period. TCM
strategies represented by Qing Fei Pai Du Tang have shown apparent advantages in im-
proving symptoms, promoting virus clearance, and shortening hospitalization, as well as
Correspondence to: Associate Prof. Wei-Hong Li, Basic Medical College, Chengdu University of Traditional
Chinese Medicine, 1166 Liutai Avenue, Wenjiang District, Chengdu, Sichuan 611137, P. R. China. Tel: (þ86)
28-6180-0051, Fax: (þ86) 28-6180-0051, E-mail: lwh@cdutcm.edu.cn
a
These authors contributed equally to this work.
1035
1036 Z.-H. ZHAO et al.
surprising efficacy of zero patient progressing from mild to severe cases in a TCM cabin
hospital. Clinical data illustrate the effectiveness of TCM strategies proposed by the Chinese
government. This major epidemic may bring new opportunities for TCM development.
Keywords: Coronavirus Disease-2019; COVID-19; Traditional Chinese Medicine Diagnosis

and Treatment Strategies; Qing Fei Pai Du Tang; Diagnosis and Treatment Program for
Coronavirus Disease-2019; Review.
Introduction
Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2), is characterized by strong epidemics, infectiousness, and
severe harm (Zhu et al., 2020). Since the first case reported in Wuhan City in December
2019, COVID-19 has swept across China and other countries around the world with rapid
momentum, causing huge personal and property losses (Bernard Stoecklin et al., 2020;
Holshue et al., 2020; Phan et al., 2020). The Chinese government has adopted active and
effective multidisciplinary prevention and control measures to address substantial COVID-
19 transmission, including the introduction of the seven versions of the Diagnosis and
Treatment Program of Coronavirus Disease-2019 (hereinafter referred to as Program)
(Wu and McGoogan, 2020). The Program describes the etiology, epidemiological char-
acteristics, clinical manifestations, diagnostic criteria, and treatment methods of COVID-19
in detail and standardizes the deisolation conditions and nosocomial infection management,
accompanied by a promising highlight: the application of traditional Chinese medicine
(TCM) (National Health Commission of the People’s Republic of China, 2020a,b,c,d,e,f,
g). TCM has been promoted globally because of its advantages in relieving fever symp-
toms, controlling disease progression, and reducing complications during the treatment of
severe acute respiratory syndrome (SARS) 17 years ago (World Health Organization,
2004). In the current COVID-19 struggle, a status transformation of TCM is being dem-
onstrated from a participant to a leading force. Based on the changes in TCM diagnosis and
treatment strategies in these seven versions of Programs, this paper explored the TCM
etiology, COVID-19 pathogenesis, syndrome differentiation, and treatment methods, and
reviewed the current efficacy of its recommended prescriptions for COVID-19 to update
the clinician’s TCM knowledge in this field.
Adjustments of TCM Diagnosis and Treatment Strategies in the Seven Programs
Analysis of Possible Factors for Incorporating TCM Strategies into the Program,
the 3rd Edition
COVID-19 is an unprecedented acute respiratory infectious disease with acute onset and
rapid deterioration. Severe patients characteristically experience dyspnea or hypoxemia
within a week, followed by rapid progression of acute respiratory distress syndrome,
septic shock, metabolic acidosis, coagulopathy, and multiple organ failure (National Health
TCM DIAGNOSIS AND TREATMENT STRATEGIES FOR COVID-19 1037
Commission of the People's Republic of China, 2020e). Due to the increasing number of
infected patients and limited isolation wards at the beginning of the epidemic, only
critical patients experiencing a life-threatening situation could be admitted to the hos-
pital with Western medicine-dominated treatment measures. For this reason, Western
medicine appeared to be the primary intervention in the 1st and 2nd editions of the
Program. However, the Chinese government has adopted active responses and rapid
deployments since the outbreak, including remodeling the designated hospitals and the
cabin medical system for COVID-19 patients and deploying medical resources to
support Wuhan. At the same time, TCM measures that have achieved significant results
have been widely used, including identifying designated TCM hospitals, wards, and
cabin medical systems with integrated TCM and Western medicine as the primary
treatment mode. Therefore, TCM treatment was added in the 3rd edition and gradually
improved in the 4th to 7th editions, forming a unique TCM diagnosis and treatment
system.
Adjustments of Staging and Classifications of COVID-19 and the Clinical Values
TCM disease name, underlying pathogenesis, and syndromes of COVID-19 were deter-
mined in the third edition that was developed at the beginning of the outbreak. At that time,
severe and critical cases consisted of main observation objects, resulting in strategies
focusing on the transmission law of critical cases, that is, “heat formation” as the key.
At the time of the formulation of the 4th and 5th editions, many medical resources were
dispatched to assist Wuhan so that mild and suspected cases could be hospitalized. In
addition, some patients who had previously received treatment have entered the recovery
stage. Based on the observation of these patients, a complete understanding of COVID-19
from the initial stage to the recovery stage has been formed, and TCM is recommended
throughout the disease, including the ultra-early stage-suspected cases. More detailed
strategies were identified in the 6th and 7th editions, including syndromes corresponding to
Western medicine stages (mild case, ordinary case, severe case, and critical case), two
pathogenic progresses of heat and cold formation, and a basic formula for confirmed cases,
Qing Fei Pai Du Tang. Changes in staging and classifications in these seven Programs are
detailed in Table 1.
Cognition of COVID-19 in TCM Strategies
TCM Disease Name and Etiology of COVID-19 and their Clinical Values
COVID-19 corresponds to “pestilence” in the Programs (the 3rd to 7th edition) for its
strong epidemic and infectiousness, with “epidemic pathogen” as its etiology. According to
TCM, epidemic pathogens are pathogenic factors distinct from six excesses, that is, wind,
cold, summer heat, dampness, dryness, and fire and are characterized by “contact means
infection” and “each disease has its own causative factors”. A recently published study of
genome sequences suggested a weak connection between SARS-CoV-2 and SARS-CoV
Table 1. Similarities and Differences of TCM Diagnosis and Treatment Strategies in Seven Versions of
Programs
The 3rd Edition The 4th and 5th Edition The 6th and 7th Edition
Issuing time Jan. 22 The 4th edition: Jan. 27 The 6th edition: Feb. 18
The 5th edition: Feb. 5 The 7th edition: Mar. 3
Disease name Pestilence
Etiology Epidemic pathogen
Staging — Divided into medical observation Divided into medical observation

period and clinical treatment period and clinical treatment
period. The latter includes period. The latter includes mild
early-stage, middle-stage, case, moderate case, severe
severe-stage, and recovery- case, critical case, and

stage. recovery-stage.
Syndrome Dampness stagnating Early-stage: cold-dampness Mild case: cold-dampness
differentiation the lung syndrome obstructing the lung obstructing the lung syndrome
syndrome. and dampness-heat accumulat-
ing the lung syndrome.
Heat-toxin obstructing Middle-stage: epidemic toxin Moderate case: cold-dampness
the lung syndrome blocking the lung syndrome. stagnating the lung syndrome
and dampness-toxin blocking
the lung syndrome.
Epidemic toxin Severe-stage: internal block and Severe case: epidemic toxin
blocking the lung external collapse syndrome. blocking the lung syndrome
syndrome and dual blazing of qi-nutrient
aspects syndrome.
Internal block and ex- Recovery-stage: deficiency of Critical type: internal block and
ternal collapse lung-spleen qi syndrome. external collapse syndrome.
syndrome Recovery-stage: deficiency of
lung-spleen qi syndrome and
dual deficiency of qi and yin
syndrome.
Treatment TCM formulas Medical observation period: Medical observation period: CPMs
CPMs a
Early-stage: TCM formulas A basic formula for confirmed
case-Qing Fei Pai DuTang
Middle-stage: TCM formulas and Mild case: TCM formulas
CPMs
Severe-stage: TCM formulas and Moderate case: TCM formulas
CPMs
Recovery-stage: TCM formulas Severe case: TCM formulas and
CPMs
Critical case: TCM formulas and
CPMs
Recovery-stage: TCM formulas
a CPM: Chinese patent medicine.
(approximately 79%) and MERS-CoV (approximately 50%), indicating a correspondence

of substantial transmission and high specificity in pestilence (Lu et al., 2020).
“Dampness-toxin” is particularly emphasized in pestilence. “Toxin” has two meanings:
one is that the disease has strong pathogenicity, and the other is that the disease is char-
acterized by warm heat. A study found that the rainfall in January 2020 in Wuhan was 4.6
times the average rainfall in the same period in the past 20 years, which aggravated the evil
of cold-dampness and formed a high incidence of being infected by dampness-toxin (Tong
et al., 2020). In addition, a study of the clinical characteristics of 1099 COVID-19 patients
from 552 hospitals in China found that these patients may experience cough (67.8%),
sputum production (33.7%), dyspnea (18.7%), sore throat (13.9%), fatigue (38.1%),
headache (13.6%), myalgia or arthralgia (14.9%), nausea or vomiting (5.0%), diarrhea

(3.8%), and a dynamic fever process (43.8% at admission to 88.7% during hospitalization)
(Guan et al., 2020). According to TCM, fatigue, diarrhea, nausea, and vomiting are as-
sociated with the invasion of dampness-toxin, whereas sore throat and a dynamic fever
process are linked to features of warm and an easy conversion into heat.
TCM Theory Based COVID-19 Pathogenesis and its Clinical Value
As mentioned in the 3rd edition, based on TCM theory, the underlying pathogenesis of
COVID-19 is characterized by “dampness, heat, toxin, and stasis”. The changes of syn-
dromes and stages in the 3rd to 7th editions showed a process from vagueness to clarity in
the understanding by TCM.
A rapidly developing process was introduced in the 3rd edition, that is, epidemic
pathogen invading the body, followed by entering the internal organs and transforming into
heat, resulting in pathogen trapping in the interior and healthy qi collapsing. Other views
were subsequently added to the medical observation period and recovery period in the 4th
and 5th editions. Finally, the pathological process of “heat entering nutrient aspect” and the
outcome of “qi and yin deficiency” were complemented in the 6th and 7th editions. TCM
based COVID-19 pathogenesis can be summarized as an “epidemic pathogen invading the
body, followed by entering the internal organs and transforming into heat, resulting in
pathogen trapping in the interior and healthy qi collapsing, and deficiency of qi and yin”.
According to TCM, the epidemic pathogen that enters the body through the mouth and
nose first lurks in the body without onset, which coincides with the concept of respiratory
transmission and incubation period in COVID-19. In addition, TCM believes that the lung
opens at the nose. Therefore, the lung is most easily affected by the epidemic pathogen,
resulting in various pulmonary symptoms and lung imaging changes that are consistent
with modern medical autopsy results presented by low airway and alveolar injury in
COVID-19 (Liu et al., 2020). In addition, many patients may experience diarrhea and
abdominal distension in the early stage on account of dampness-toxin obstructing the
spleen and stomach, which has also been a concern in modern medicine (Liang et al.,
2020).
Two pathological states in the early stage, cold or heat formation, are shown after the
onset of pestilence depending on individuals’ constitution, climate, and so on. Among all
these factors determining cold and heat formation, epidemic pathogen, which is charac-
terized by warm nature, may be the most vital one. The invasion of the warm-natured
pathogen may increase the body’s thermal properties, resulting in a more frequent oc-
currence of heat formation that can be demonstrated by a high incidence of fever in clinical.
Another critical factor is the individuals’ constitution. TCM regards the formation of a
disease as the development of a biased constitution (Li et al., 2019). Therefore, a damp-
ness-heat constitution may lead to heat formation (Sang et al., 2018). In cold formation,
cold-dampness enters the internal organs and blocks the lung, resulting in mild cases and
moderate cases with cold-dampness stagnating the lung. In contrast, in heat formation,
dampness-heat invades the lung, and thereby mild cases of dampness-heat obstructing the
lung and moderate cases of dampness-toxin blocking the lung are formed. Then the epi-
demic pathogen rapidly transforms into the fire resulting in severe cases of epidemic toxin
blocking the lung or penetrates deeply in the nutrient aspect resulting in severe cases of
dual blazing of qi-nutrient aspects, or even blocks internal organs and exhausts qi and yin
resulting in critical cases of internal block and external collapse. It is worth mentioning that
cold formation is relatively rare due to the warm-natured pathogen, a considerable part of
which eventually transforms into heat formation on account of the theory that “long-term
accumulation can generate heat”. As a result, cold formation is often seen as a transient
segment rather than the whole process in the pathogenesis. A study on the relationship
between syndromes and onset days found that the median onset day was different in
various syndromes. Namely, the syndrome of cold-dampness obstructing the lung was on
day 6.5, the syndrome of dampness-heat accumulating the lung was on day 10, and the
syndrome of dampness-toxin blocking the lung was on day 11.5, indicating that the long-
term accumulation of cold-dampness can turn into heat, resulting in the combination of
dampness and heat (Xu et al., 2020a).
If the above pathological process is corrected, qi and yin may be depleted with the
expulsion of the epidemic pathogen. Therefore, deficiency of lung-spleen qi syndrome and
dual deficiency of qi and yin are displayed during the recovery stage.
The Principle of COVID-19 Syndrome Differentiation and its Clinical Value
For the convenience of clinicians, we believe that heat formation should be emphasized
during syndrome differentiation. Body temperature may serve as an essential factor.
Symptoms such as low fever, no fever, aversion to cold, fatigue and hypodynamia, gen-
eralized heaviness, pale or pale red tongue, and white fur may be considered indicators of
mild cases and ordinary cases with cold dampness stagnating the lung. In contrast, man-
ifestations such as high fever, alternating chills and fever, sore throat, muscle soreness, red
tongue, yellow fur, and rapid pulse should be associated with mild cases of dampness-heat
obstructing the lung and ordinary cases of dampness-toxin blocking the lung. Then the
epidemic pathogen continues to progress rapidly and symptoms linked with severe cases of
epidemic toxin blocking the lung and dual blazing of qi-nutrient aspects appear, including
persistent fever, yellow phlegm, oppression in the chest with anhelation, cough with
wheezes, panting on exertion, abdominal distension, constipation, mental confusion,
delirium, hemoptysis, epistaxis, dark purple tongue with thick slimy and dry fur, crimson
tongue with little or no fur, and slippery and rapid pulse. Finally, symptoms defined as the
external collapse in TCM are displayed, including dyspnea, panting on exertion requiring
assisted ventilation, coma, agitation, cold limbs with cold sweating, dark purple tongue,
thick or dry thick fur and a floating and rootless pulse. More importantly, the manifesta-
tions of various syndromes can appear in one patient at the same time due to the rapid
progress and a transformation from cold to heat formation, which increases the difficulty of
diagnosis.
In the recovery stage, symptoms such as lassitude of spirit, lack of strength, sponta-
neous sweating, epigastric fullness, and torpid intake are associated with deficiency of
lung-spleen qi, and manifestations of dry mouth and thirst, night sweating, tidal fever, red
tongue, and fewer fur are considered as qi and yin deficiency.
The Basic Formula of COVID-19-Qing Fei Pai Du Tang and its Clinical Value
The corresponding treatment principles are proposed for various syndromes in the
Program, the 7th edition, but the general treatment tenet is to resolve dampness, remove
toxin, reinforce healthy qi, and eliminate pathogenic factors (Li et al., 2020). In the early
stage, when epidemic factors are still superficial, dampness-resolving and exterior-releas-
ing medicine are used to thrust pathogens out through the exterior. In the middle stage,
when epidemic factors transform into heat and enter the interior, fire-downbearing and
detoxication medicine serve as main measures to discharge heat-toxin through the bowels.
In the terminal stage of internal block and external collapse, it is advisable to break the
block and secure healthy qi to save from collapse.
Requiring treatment methods tailored to various syndromes and personal constitutions,
the herbal formula composed of several herbs after diagnosis is the most commonly used
TCM mode. Although with widespread transmission, most COVID-19 patients are not
critically ill. Therefore, the Chinese government has set up many cabin hospitals in Wuhan
in a short time to treat mild and ordinary cases. In the absence of a vaccine or therapeutic,
TCM is the primary method to respond to nonlife-threatening but painful symptoms.
Although the respective syndrome-based prescriptions are recommended in the 3rd to 7th
editions. A basic formula, Qing Fei Pai Du Tang, applicable to all COVID-19 patients,
especially nonsevere individuals, was introduced in the 6th and 7th editions for the con-
venience of non-TCM practitioners. According to official data, as of February 29, 1183
cases under the treatment of Qing Fei Pai Du Tang had shown a good prognosis, including
640 who had been discharged, and 457 who had improved symptoms (Joint Prevention and
Control Mechanism of the State Council, 2020). A small sample of Qing Fei Pai Du Tang
for COVID-19 found evidence of a significant improvement in lymphocyte percentage on
the 3rd day (P < 0:01), and C-reactive protein and erythrocyte sedimentation rate on the
6th day (P < 0:01). In addition, significantly improved symptoms have been shown since
the 3rd day, and symptoms including fever, chills, cough, yellow urine, and cyanosis with
effective rates of 95.83%, 96.77%, 92.59%, 93.33%, and 93.33%, respectively, were
shown on the 9th day (Wang et al., 2020).
Qing Fei Pai Du Tang is made from four formulas (Ma Xing Shi Gan Tang, She Gan
Ma Huang Tang, Wu Ling San, and Xiao Chai Hu Tang) (National Health Commission and
State Administration of Traditional Chinese Medicine, 2020f). The specific herbs and
effects are shown in Table 2 (National Health Commission of the People’s Republic of
China, 2020). Wu Ling San and She Gan Ma Huang Tang, focusing on “cold formation”,
are used to disperse cold dampness in the whole body and lungs, whereas Xiao Chai Hu
Tang and Ma Xing Shi Gan Tang, focusing on “heat formation”, can clear heat in the lung
and exterior. Although covering two pathological states, Qing Fei Pai Du Tang still
focuses on heat formation to form a formula with more heat-clearing and detoxifying
drugs. Its good therapeutic effect also reversely validates the theory that heat formation is
more common. At present, the mechanism of Qing Fei Pai Du Tang is ongoing. Some
scholars had predicted through grid pharmacology that the first five active ingredients are
Table 2. Composition of Qing Fei Pai Du Tang
Modification in Qing Fei

Formula Composition Pai Du Tang Efficacy
Ma Xing Shi Gan Herba Ephedra, Semen Armenia- — Clear heat, purge fire, and
Tang cae Amarum, raw Gypsum regulate lung qi.
Fibrosum, Radix Glycyrrhizae
Xiao Chai Hu Radix Bupleuri, Radix Scutellariae, Remove Ginseng, Jujube Outthrust pathogens
Tang Rhizoma Pinelliae Preparata, through the exterior
Ginseng, Rhizoma Zingiberis and discharge heat.
Recens, Jujube, Radix
Glycyrrhizae
She Gan Ma Rhizoma Belamcandae, Herba Remove Schisandra Dissipate cold and resolve
Huang Tang Ephedra, Rhizoma Zingiberis Chinensis, Jujube retained fluid to calm
Recens, Herba Asari, Radix panting and eliminate
Asteris, Flos Farfarae, Jujube, phlegm.
Rhizoma Pinelliae Preparata,
Schisandra Chinensis
Wu Ling San Rhizoma Atractylodis Macro- — Induce diuresis, drain
cephalae, Rhizoma Alismatis, dampness, release the
Polyporus Umbellatus, Poria, exterior, and outthrust
Ramulus Cinnamomi. pathogens.
Add Rhizoma Dioscoreae, Fortify the spleen and re-
Fructus Aurantii solve dampness.
Immaturus, Peri-
carpium Citri Reticu-
latae, Herba
Pogostemonis
Note: Decoction methods: The above herbs should be decocted with water and taken warmly after meal twice per
day for three days as a course of treatment. Half a bowl of rice soup is recommended after medication if the
conditions permit, and the dosage can be doubled in patients with fluid deficiency. The dosage of raw gypsum
should be decreased for patients without fever and be increased for patients with high fever. Take the second
course of treatment if the symptoms are improved but not disappeared. The medicine should be discontinued if the
symptoms disappear.
quercetin, luteolin, kaempferol, naringenin, and isorhamnetin, which may regulate targets
including MAPK1, MAPK3, MAPK8, MAPK14, IL-6, RELA, and STAT1, as well as
signal pathways including NF-κB to inhibit inflammatory responses and regulate immune
functions, thereby reducing lung injury and protecting neural functions (Xu et al., 2020b).
Some previous studies illustrate this point. A study demonstrated the anti-inflammatory
effects of Wu Ling San in lipopolysaccharide-stimulated macrophages by affecting various
mechanism pathways including NF-κB, MAPKs and HO-1 (Oh et al., 2014). Another work
indicated that She Gan Ma Huang Tang had antiviral activity against coxsackievirus B4-
induced cellular injuries in airway mucosa by preventing viral attachment (P < 0:0001),
internalization (P < 0:0001), and replication (P < 0:0001) (Yen et al., 2014).
Application of Chinese Patent Medicines and their Clinical Value
Chinese patent medicines (CPMs) are widely used due to the advantages of stable dosage
forms and accessible administration in oral medication, as well as rapid blood entry and
effect onset in injections. Recommendations of oral CPMs in the medical observation
period and Chinese herbal injections in severe cases and critical cases in clinical treatment
period make TCM more suitable for clinical promotion since the 4th edition. The
recommended CPMs in the 7th edition are shown in Table 3.
Lian Hua Qing Wen is the most frequently studied CPM among the medicines men-
tioned above. Given the effects of broad-spectrum antiviruses and the regulation of the
immune response, Lian Hua Qing Wen capsule is widely used in China to combat various
respiratory infectious diseases (Ding et al., 2017). A study on the Lian Hua Qing Wen
capsule for influenza A (H1N1) found that those randomized to the Lian Hua Qing Wen
group did not have significant overall differences in the median duration of illness (Lian
Hua Qing Wen 69 h vs. oseltamivir 85 h, P > 0:05) and median duration of viral shedding
Table 3. CPMs Recommended in the 7th Edition
Period CPMs
Medical observation Hypodynamia with gastrointestinal discomfort: Huo Xiang Zheng Qi capsule
period (oral medi- (pill, liquid, or oral liquid).
cation)
Hypodynamia with fever: Jin Hua Qing Gan granule, Lian Hua Qing Wen
capsule (granule), Shu Feng Jie Du capsule (granule).
Clinical treatment pe- Severe case Xi Yan Ping injection, Xue Bi Jing injection, Re Du Ning
riod (injection) injection, Tan Re Qing injection, Xing Nao Jing
injection.
Critical case Xue Bi Jing injection, Re Du Ning injection, Tan Re Qing
injection, Xing Nao Jing injection, Shen Fu injection,
Sheng Mai injection, Shen Mai injection.
(Lian Hua Qing Wen 103 h vs. oseltamivir 96 h, P > 0:05) compared with the oseltamivir
group but did report increases in the severity of illness and the duration of symptoms
including fever, cough, sore throat, and fatigue (P < 0:05) (Duan et al., 2011).
Unfortunately, evidence that evaluates the efficacy of Lian Hua Qing Wen in coro-
navirus infected diseases is lacking. However, a recently published controlled trial
concluded that Lian Hua Qing Wen combined with conventional Western medicine is
superior to conventional Western medicine in improving symptoms including fever,
cough, fatigue, and shortness of breath (P < 0:05) in suspected cases (Lu et al., 2020).
Another retrospective study suggested that Lian Hua Qing Wen was more effective at the
disappearance rate and time of main symptoms, including fever, cough, and fatigue
(P < 0:05) than the blank control but showed no significant difference in chest CT
improvement (P > 0:05) (Cheng et al., 2020). However, problems such as the small
sample size and nonrigorous randomized control design in this study reduce the credi-
bility of the results.
Chinese Herbal Injections are Activated
In recent years, Chinese herbal injections, which are controversial, have been praised for
effectiveness and improvements in specific and critical diseases in some studies and have
been criticized for safety in more studies (Huang et al., 2019). A recently published
study found that age (P ¼ 0:048) and coadministration of ribavirin (P < 0:001) may be
considered potential risk factors of adverse drug reactions of Xi Yan Ping injection
(Zheng et al., 2020). Another study showed that skin and subcutaneous tissue disorders
(1.3%) were the most common adverse drug reactions associated with Tan Re Qing
injection, and the majority (72.8%) of adverse drug reactions occurred in the first 2 h
after administration (Li et al., 2019). Therefore, the indications and usage of Chinese
herbal injections are recommended in the 7th edition with strict adherence to the
instructions, and elderly patients using combined medicine should be treated with
caution (Table 3).
To date, TCM has shown extraordinary achievements. In Wuhan TCM cabin hos-
pital, which was dominated by pure TCM treatment, none of the patients progressed to
severe status (World Wide Web, 2020). Some small-scale work has demonstrated the
advantages of TCM in shortening hospitalization and improving symptoms. A recently
published retrospective study of integrated TCM and Western medicine treatment for 67
nonsevere cases in Shanghai showed a significant reduction in hospitalization and
symptom scores on the 6th day of admission (P < 0:05), but no difference in the total
disease duration, antipyretic time, or CT improvement rate (P > 0:05) (Shi et al., 2020).
As we know, randomized controlled trials (RCTs) are necessary to conclude the
effectiveness of TCM in any specific disease. However, for a devastating epidemic
outbreak such as COVID-19, more retrospective study reports rather than rigorous large
RCTs can be found.
TCM Nondrug Therapies Show Promise
In recent years, pulmonary rehabilitation has been widely used in severe and chronic
respiratory diseases (Richardson et al., 2019). In addition to conventional methods,
including aerobic exercise, strength training, and education (Spruit et al., 2013), al-
ternative treatments such as tai chi, yoga and acupuncture are gradually being accepted
by Western society (Cai and Shen, 2018; Pan et al., 2018; Yu et al., 2018). Previous
studies have reported that qigong and taijiquan may enhance oxygen carrying capacity
and improve anxiety and depression (Lan et al., 2004; Yeung et al., 2018; Chang et al.,
2019). Although not mentioned in the Program, TCM rehabilitation methods covering
taijiquan and baduanjin are used in COVID-19 patients including critical cases. Since
the outbreak of COVID-19, many TCM intervention trials have appeared on the website
of the China Clinical Trial Registry, including TCM decoctions, Chinese patent med-
icines, TCM psychotherapies, and TCM massage therapies. In addition, high-level
clinical evidence is expected to prove the efficacy of TCM.
In addition, previous evidence has suggested that TCM also has a role in preventing
viral infections (Lin et al., 2013; Li et al., 2018). A controlled trial of TCM for
preventing SARS infection among medical staff found that none of the TCM consumers
contracted the SARS infection, while a 0.4% incidence was shown among non-TCM
consumers (Lau et al., 2005). A recent meta-analysis of four trials, three of which were
RCTs, found evidence of a reduction in the infection rate of influenza A (H1N1)
(relative risk 0.36, 95% confidence interval 0.24–0.52, P < 0:01). However, this
conclusion should be treated with circumspection due to concerns about methodology
(Luo et al., 2020).
The Vicissitudes of the Programs are the Embodiment of the Efficacy

and Advantages of TCM
TCM’s understanding and advantages of COVID-19 have been demonstrated in the

vicissitudes of the Program. COVID-19 is close to the TCM disease of pestilence, and
its pathogenesis can be summarized as an “epidemic pathogen invading the body,
followed by entering the internal organs and transforming into heat, resulting in
pathogen trapping in the interior and healthy qi collapsing, and deficiency of qi
and yin”. Heat formation should be emphasized in syndrome differentiation. The
manifestations of qi deficiency and yin deficiency are exhibited during the recovery
period. TCM decoctions and CPMs are vital components of COVID-19 TCM treatment.
Although the evidence is inadequate, TCM, especially Qing Fei Pai Du Tang, has
shown remarkable advantages in improving symptoms, promoting virus clearance,
and shortening hospitalization. Clinical data illustrate the effectiveness of the
Chinese government’s proposed TCM strategies and the applicability of TCM to guide
today’s diseases. This major epidemic may bring new opportunities for TCM
development.
Acknowledgments
This work was supported by the National Key Research and Development Program of
China (No. 2017YFC1703304) and the National Natural Science Foundation of China
(No. 81873204). Funding bodies play an economic support role in research design.
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The American Journal of Chinese Medicine, Vol. 48, No.

Analysis of Traditional Chinese Medicine

Diagnosis and Treatment Strategies for

Treatment Program for Coronavirus

Zhi-Hui Zhao,*,a Yi Zhou,†,a Wei-Hong Li,* Qing-Song Huang,†

Chengdu University of Traditional Chinese Medicine

Published 1 July 2020

Keywords: Coronavirus Disease-2019; COVID-19; Traditional Chinese Medicine Diagnosis

Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome

Adjustments of TCM Diagnosis and Treatment Strategies in the Seven Programs

Adjustments of Staging and Classiﬁcations of COVID-19 and the Clinical Values

Cognition of COVID-19 in TCM Strategies

Staging — Divided into medical observation Divided into medical observation

severe-stage, and recovery- case, critical case, and

(approximately 79%) and MERS-CoV (approximately 50%), indicating a correspondence

headache (13.6%), myalgia or arthralgia (14.9%), nausea or vomiting (5.0%), diarrhea

TCM Theory Based COVID-19 Pathogenesis and its Clinical Value

The Principle of COVID-19 Syndrome Differentiation and its Clinical Value

Table 2. Composition of Qing Fei Pai Du Tang

Modiﬁcation in Qing Fei

Application of Chinese Patent Medicines and their Clinical Value

Table 3. CPMs Recommended in the 7th Edition

Chinese Herbal Injections are Activated

TCM Nondrug Therapies Show Promise

The Vicissitudes of the Programs are the Embodiment of the Efﬁcacy

TCM’s understanding and advantages of COVID-19 have been demonstrated in the

Bernard Stoecklin, S., P. Rolland, Y. Silue, A. Mailles, C. Campese, A. Simondon, M. Mechain,

Levy-Bruhl and T. Investigation. First cases of coronavirus disease 2019 (COVID-19) in

Chin. Materia Medica. 36: 26–32, 2020b.

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Zhi-Hui Zhao,,a Yi Zhou,†,a Wei-Hong Li, Qing-Song Huang,†