key: cord-313056-wuo7zerg authors: Portella, Caio Fabio Schlechta; Ghelman, Ricardo; Abdala, Carmen Verônica Mendes; Schveitzer, Mariana Cabral title: Evidence map on the contributions of traditional, complementary and integrative medicines for health care in times of COVID-19 date: 2020-07-15 journal: Integr Med Res DOI: 10.1016/j.imr.2020.100473 sha: doc_id: 313056 cord_uid: wuo7zerg BACKGROUND: Due to the pandemic, there is a significant interest in the therapeutic resources linked to TCIM to support potentially therapeutic research and intervention in the management of COVID-19. At the date of this evidence map´s publication, there is no evidence of specific treatments for Coronavirus - 19 (COVID-19). This map organizes information about symptoms management (especially on dimensions related to mental health and mild viral respiratory infections, as well as immune system strengthening and antiviral activity). METHOD: This evidence map applies methodology developed by Latin American and Caribbean Center on Health Sciences Information based on the 3iE evidence gap map. A search was performed in the Traditional, Complementary and Integrative Medicine Virtual Health Library and PubMed, using the MeSH and DeCS terms for respiratory viral diseases associated with epidemics, COVID-19 symptoms, relevant mental health topics, pharmacological and non-pharmacological interventions related to TCIM. RESULTS: For the map, 126 systematic reviews and controlled clinical studies were characterized, distributed in a matrix with 57 interventions (18 phytotherapy, 9 mind-body therapies, 10 traditional chinese medicine, 3 homeopathic and anthroposophic dynamized medicines and 17 supplements), and 67 outcomes (14 immunological response, 23 mental health, 25 complementary clinical management of the infection and 5 other). DISCUSSION: The map presents an overview of possible TCIM contributions to various dimensions of the COVID-19 pandemic, especially in the field of mental health, and it is directed to researchers and health professionals specialized in TCIM. Most of the antiviral activity outcomes described in this map refers to respiratory viruses in general, and not specifically to SARS-CoV-2 (Severe Acute Respiratory Syndrome CoronaVirus 2). This information may be useful to guide new research, but not necessarily to support a therapeutic recommendation. Finally, any suspicion of COVID-19 infection should follow the protocols recommended by the health authorities of each country/region. The World Health Organization (WHO) has been encouraging and strengthening the insertion, recognition and use of traditional, complementary and integrative medicines (TCIM), products and their practitioners in national health systems at all levels of activity: primary care, specialized care and hospital care, through the recommendations of the WHO Strategy on Traditional Medicine 2014-2023 based on the regulation of quality, safety and efficacy [1] . According to WHO, 43% of Latin American countries have legislation on TCIM, and 54% of them have a regulatory system for herbal therapies. Although 88% of WHO member states have recognized their use of T&CM, which corresponds to 170 member states, data from Latin America show a lack of mechanisms to monitor the safety of T&CM practices and safety of T&CM products (61%); lack of financial support for T&CM research (61%) [2] . Evidence maps are a useful method with the dual function of synthesizing available evidence on a specific topic and identifying knowledge gaps. It requires a systematic review of the J o u r n a l P r e -p r o o f literature and an assessment of the type and quality of available evidence. Evidence maps, unlike other synthesis methods, use graphical representations (or dynamic representations, through interactive online databases), which facilitate the interpretation of results [3] . Because of the recent COVID- 19 This evidence map summarizes TCIM interventions and health outcomes related to improved immunity/antiviral effect for respiratory viruses, treatment of symptoms of respiratory infections and contributions to mental health. We report the method and results according to PRISMA guidelines [4] and the International Initiative for Impact Evaluation (3iE) Evidence Gap Methodology [5] . This evidence map was supported by a technical expert panel of librarians, practitioners, policy maker and researcher content experts. We searched PUBMED and Traditional, Complementary and Integrative Medicine Virtual Health Library (TCIM VHL) from database inception to March 2020 for studies published in English, Spanish and Portuguese. VHL is a decentralized and dynamic collection of information sources, designed to provide equitable access to scientific knowledge on health. It is maintained by BIREME, a PAHO Specialized Center. This collection includes databases J o u r n a l P r e -p r o o f such as LILACS, MEDLINE, Cochrane Library and SciELO. We consulted topic experts and developed the search strategy together with BIREME. A search strategy was developed, using the MeSH and DeCS terms for respiratory viral diseases associated with epidemics, COVID-19 symptoms, relevant mental health topics, pharmacological interventions related to TCIM (medicinal plants/ phytotherapy, herbal medicine, Chinese and Ayurvedic herbology, drugs related to homeopathy and anthroposophic medicine, probiotics, nutritional supplements, among others), as well as non-pharmacological TCIM interventions (yoga, taichi, mindfulness, meditation, qigong, tapping, body practices, among others). The terms used in the search strategy were reviewed by TCIM experts and researchers, and by librarians. • Any type of Traditional and Complementary therapies interventions, of any duration and follow up; • Controlled clinical studies; • Systematic reviews with or without meta-analyses with humans, for any age group. • Relevant non-systematic reviews; • Outcomes related to improved immunity/antiviral effect for respiratory viruses, treatment of symptoms of respiratory infections or contributions to mental health (depression, social isolation, anxiety and stress disorders including work stress); • Studies in Portuguese, Spanish, and English; • All participants of all ages regardless of health status. We excluded studies that did not focus on TCIM interventions, case reports and control case studies. Two independent literature reviewers screened the systematic review search output blinded at the software Rayyan. Citations deemed potentially relevant by at least one reviewer and unclear citations were obtained as full text. The full-text publications were screened against the specified inclusion criteria by two independent reviewers; disagreements were resolved through discussion. From each included systematic review, we extracted the intervention (e.g., mind-body therapies practice, yoga, acupuncture) and the main health outcomes (e.g., stress, anxiety, We identified 126 studies that met the criteria for inclusion in the evidence map ( Figure 1 ). The studies selected came from 12 countries. The complete list of references and the interactive evidence map can be accessed in the MTCI VHL, available at: http://mtci.bvsalud.org/en/contributions-of-traditional-complementary-and-integrativemedicine-tcim-in-the-context-of-covid-19/. Studies included were designed as randomized controlled studies (n=60), non-randomized controlled studies (n=6), Coorte (n=1), prospective (n=5), retrospective (n=1), observational (n=8), meta-analysis (n=8), evidence maps (n=3), systematic reviews (n=16), systematic reviews with metanalysis (n=12), narrative reviews (n=9), scoping reviews (n=2). The included studies presented 57 TCIM interventions divided into five major groups: phytotherapy (18), mind-body therapies therapies (9), traditional chinese medicine interventions (10), Homeopathic and Anthroposophic dynamized medicines (4) and Supplements (17), as presented in Table 1 . TCIM was evaluated as an intervention for several health outcomes. The 126 studies showed 67 outcomes in total divided into major groups: immunological response (14) ; mental health (23) ; complementary clinical management of the infection (25) and Others (5) . Every outcome effect was classified, more than one outcome for some studies: 1 as potential negative [6] ; 6 as no effect; 14 as inconclusive; 78 as potential positive and 47 as positive J o u r n a l P r e -p r o o f (Fig.2) . Effects classification was extracted from mapped studies' results as reported by their authors. The results in this category have shown for mind-body therapies and traditional chinese medicine interventions potential positive effects and positive effects. For phytotherapy and Supplements there were more studies indicating potential positive and positive effects than studies indicating no effect or inconclusive effect, and for dinamized medicines the findings showed inconclusive, potential positive results and in only one study did it show one potential negative effect, headache [6] . Also, in this category, a systematic review points out the relevance of the use of probiotics [7] for the prevention of respiratory diseases in hospitalized patients, as well as for the improvement of the immunological [8] condition as a preventive resource for cases of aggravation of the disease. Another systematic review demonstrates that the use of prebiotics and probiotics can improve the efficiency of vaccines against influenza family viruses[9] a factor of great relevance for future research. In the phytotherapy category, other clinical studies on immunostimulating activity of Echinacea purpúrea [10] Viscum album [11] , individualized chinese herbal therapy [12] and Wolfberry [13] stand out. The Viscum album has been employed mainly by the complex medical system of anthroposophic medicine. In general, research on vitamin supplementation using Vitamin C, Vitamin D, Selenium, and other nutrients for immunological efficiency stands out as relevant only in cases of nutritional deficiency [14] [15] [16] . This category included outcomes only related to mind-body therapies, phytotherapy and traditional chinese medicine. There was a mix of potential positive, positive, inconclusive and no effect outcomes. Findings in this category point to resources for post-traumatic stress disorder, relevant in a situation of pandemic and social isolation, in this category mind-body therapies and yoga [17] [18] [19] [20] , meditation techniques [21] [22] [23] and acupuncture [24] stand out. Other resources that promote resilience are highlighted from mindfulness [25] meditation techniques with the reduction of negative affective symptoms [26] , as well as factors such as stress [27, 28] , anxiety and depression [28] [29] [30] [31] [32] . Aromatherapy resources are also described for application in cases of anxiety [33, 34] . The results of the group were mostly potentially positive and positive effects with only two inconclusive outcomes. The results also call attention to evidence of various formulations for respiratory symptoms present in COVID-19, these being potential resources for management of symptoms such as fever, body pain, runny nose and other symptoms. [35, 36] The interventions with the greatest number of publications showing a positive effect refer to chinese herbology, with systematic reviews bringing relevant conclusions for the treatment of symptoms in acute respiratory syndromes [37] [38] [39] [40] . Additionally, we found studies with good positive results from prospective controlled clinical studies with the herbal medicines Sambucus nigra [41] and Allium Sativum [16] besides anthroposophic remedies [35, 42] . America is now the epicenter of the pandemic worldwide [43] . Despite the need for evidencebased treatment for COVID-19, another health problems are related to the pandemic, such as mental health problems and management of respiratory infections symptoms. The creation and publication of evidence maps consists of graphically representing the best evidence found, analyzed and categorized, in addition to linking with the bibliographic records and full texts (when available) of the studies in order to facilitate access to information for all those interested. Although evidence maps have several limitations, such as the fact that we only used published reviews to provide an overview of the research and that no further evidence was included, for example qualitative studies. We did not calculate effect sizes in a meta-analysis, neither provide risk of bias assessments, but we tried to overcome these limitations by relying on the author's skills in conducting and evaluation the studies quality, choice of outcomes, analysis of effects and susceptibility to publication and outcome reporting bias. This evidence map will also not be able to answer more refined questions, such as the most adequate TCIM application, difference between health services, adequate training for practitioners, access of patients and self-application effects. Future research, including qualitative research and case studies, are necessary to answer these questions, extremely We recommend that any suspicion of COVID-19 infection should follow the protocols recommended by the health authorities of each region. CFSP and MCS drafted the manuscript. All authors designed the study, designed and executed the search strategy and were involved in data acquisition and analysis. All authors were involved in the interpretation of the data and contributed to the final manuscript. All authors read and approved the final manuscript. 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Evidence-Based WHO Coronavirus disease (COVID-19) outbreak situation