Since the World Health Organization recognition as pandemic, the novel corona virus disease was noted to spread efficiently all over the world through respiratory droplets and contact routes [1-4 The common presenting clinical features are fever, dry cough, muscle pains, lethargy, fatigue and breathlessness. While other symptoms like diarrhea, nausea, vomiting, anosmia are also present in some patients. It is also evident that around 80% of the infected individuals are asymptomatic but are potential sources for transmission of infection to healthy individuals [5]. The infection has become a serious burden on the administration, government and health care workers. In the absence of specific treatment to SARS-CoV-2, social distancing, using facial masks, hand washing and improving immunity are the only sources of prophylaxis available currently [6-7]. Unlike general population, the health care workers can’t maintain social distancing, are at high risk of infection, hence they need additional interventions and protection [8]. The national task force has emphasized the use of Hydroxychloroquine as prophylactic measure for health care workers which might have some serious complications and adverse effects [9]. Uttar Pradesh University of Medical Sciences, a premier health care University Hospital and research center has formulated Raj Nirwan Quath(RNQ) [10] and Raj Nirwan Bati (RNB) [11] based on various minerals and herbs to improve the immunity against the SARS-CoV-2. These formulations were given to the health care workers of the University Hospital. 

Aims and objectives

The aim of the study is to assess the effect of RNQ as a prophylactic measure among the health care workers for combating SARS-CoV-2 infection.

Objectives

• To review the risk of developing the infection among the health care workers who were working in COVID-19 hospitals in our university

• To access and analyze the prophylactic effects of RNQ among the COVID-19 hospital health care workers

The study was conducted at level-3 COVID-19 hospital in Uttar Pradesh. Out of 1767 health care workers, 1255 health care workers including physicians, surgeons, intensive care specialists, nurses, technicians(medical), physiotherapists, ward boys and sanitation workers, who performed the duty in the COVID hospital of the university, were recruited for this study to analyze the prophylactic effects of RNQ (Table 1). 

Table 1: Details of Health Care Workers of the University

* One ward boy and one nurse were from the general hospital of the university and 3 nurses were infected from external sources outside the university.

The health care workers were given RNQ [10] during their duties. All the health care workers and supporting staff were given prior training on donning and doffing of PPE (personal protective equipment), social distancing and hand hygiene techniques. Mouth mask was made mandatory for all the staff of the university by the authorities. After a period of 14 days of their duties in COVID hospital, the 1255 health care workers were screened for the symptoms and Lab diagnosis for SARS-CoV-2. The rest of the health care workers and other teaching and non teaching faculty, supportive staff were also trained for RNQ decoction preparation and were advised to take regularly as a prophylactic measure. These were given 100ml, 2 times a day at 11 am and 5 pm. Ethical clearance had been received from the University's Ethics Committee/Corona committee of the University.

Out of 1767 health care workers, 1255 heath care workers were recruited in the COVID hospital and all were negative for SARS CoV-2 after the performance of COVID duty. None of the COVID hospital posted health care workers were infected with SARS CoV-2. From Non COVID hospital health care workers, 5 other health care workers (4 nurses and 1 ward boy) were positive for RT-PCR with COVID-19 who did later declared as advised by the university. One ward boy and one nurse were from the general hospital of the university and 3 nurses were infected from external sources outside the university. Two employees of the university, one administrative staff and one nursing teaching faculty were infected from COVID-19 from a source outside the university (Table 2).

Table 2: Summary of Covid -19 Postive Cases in the University

SARS-CoV-2 is a serious health problem causing burden on health care workers globally. Despite the use of PPE and proper hand hygiene techniques, the health care workers have been reported to be infected world-wide. According to the report of ICMR (Indian Council of Medical Research), till 30^th April 2020, around 5 % of the total confirmed COVID-19 cases in India constituted by health care workers [12] whereas in this institute only 0.30% non –COVID health care workers were infected. In a study by Center for Infectious Disease Research and Policy (CIDRAP), reported that 1% of the health care workers had COVID-19 globally emphasizing the serious threat to health care workers [13]. According to a Newspaper report on 6^th May, 2020, in India, around 548 doctors, nurses, paramedics were infected with COVID-19 [14]. Around 69 doctors were infected in the National capital territory with COVID-19, 10 health care workers from All India institute of medical sciences (AIIMS), the national premier health care institute were infected. The health care workers often involved in nasopharyngeal swab collection, endotracheal intubation or respiratory suctioning potentially generating aerosols from the respiratory tract [15].

By March 2020, 3 nurses from Kerala, 1 resident doctor from Bihar, 1 doctor from Bangalore, 1 doctor from Rajasthan and 1 from Mumbai were affected by COVID-19. By April 22, 2020, 156 Nurses, 96 doctors, 15 Medical workers, 11 hospital staff and technicians were infected by COVID-19. Till 30, May 2020, 31 doctors and 3 nurses lost their lives due to COVID-19 [16]. In Bhilwara, Rajasthan, India, all 16 positive cases are among health-care professionals in a single hospital [17]. In Italy alone by March 2020, around 2600 Health care workers were infected by COVID-19 during their duties. Even in well developed and highly sophisticated medical facilities available countries like United states of America, around 800 health care workers were infected by COVID-19 [18]. In England, the black, Asian and minority ethnic doctors working in National health services were over presented in early deaths. In total, 63% of health and social care workers died due to COVID-19 [19]. In Hong kong, 22% of health care workers were affected during COVID-19 duties [20]. National Health Commission of China reported that more than 3300 health care professionals were infected by COVID-19 in the month of March, 2020 [21].

In this study to analyze the prophylactic effects of RNQ among the health care workers, the results shown that 100% (N=1255) of health care workers were not affected by COVID-19 during the working period in COVID hospital. The Uttar Pradesh University of Medical Sciences ( UPUMS), Saifai, Etawah, India is a premier dedicated medical university having excellent sophisticated infrastructure for running various Medical and health care courses. The University has Hospital with advanced medical care facilities with highly qualified faculty, Specialists, Nurses and other paramedical staff. The University employs about 2300 employees including Medical doctors, faculty members, technicians, administrative staff, Nurses and other health care workers. There were zero deaths reported among the employees of the university due to COVID-19 till date. The 7 employees who were infected with COVID-19, the RNQ was given as a part of their medical management which enabled all the infected employees to recover. The University has incorporated various prophylactic measures regarding sanitation, educating the staff regarding hand hygiene, mandatory use of masks and incorporated all the social distancing norms. The staff was continuously trained about the donning and doffing of PPE kits. The University campus hoarded audiovisual aids to educated the public as well as staff about the precautionary measures, importance and correct techniques of hand sanitation, masks donning, doffing and social distancing. The university also propagated well about the RNQ as a matter of public interest. 

RNQ is a decoction made from the Large and small cardamoms (Elaichi), Ajowan (Ajwain), Cinamon (Dalchini), Curcumin (Haldi), Ginger (Adhrak), Black Pepper (Kali mirch), dry gourd (Sonth), and Tulsi [10]. These herbs have immune boosting, antibacterial, antiviral and healing properties. The most common symptoms of SARS-Cov-2 are fever, flu, non-productive dry cough, muscle pains. Small cardomoms are known for their antitussive effects since ages and were recommended by traditional medicine practitioners [22,23]. Large cardomoms, Curcumin, Cinamom, Ginger has antinflmatroy effects that can reduce the inflammation in the lungs due to corona virus [24-27] . Curcumin, Ajowon, Cinamom, Curcumin and Ginger have antiviral effects. The Black pepper, jiggeryand tulsi are hepatoprotective, as Corona virus increases mononuclear infiltrates leading to liver damage [28-32]. Tulsi is a divine herb having hepato protective, antitussive, antipyretic, antioxidant and antiviral effects. 

Despite the careful use of PPE and hand washing techniques, the health care providers are prone to develop SARS-CoV-2 infection and are at quantum risk. After the administration of RNQ, the health care workers remained immune against COVID-19 and no health care worker reported any symptoms. This gives a new light and hope to the health care workers to work confidently in the COVID-19 health care settings without any stress. The RNQ can be recommended as a prophylactic measure to the health care workers of COVID-19 nationwide and globally as to promote safe working style in COVID-19 and preventing the Occupational hazard. This study also concludes that mortality rates can be reduced and deaths can be prevented after using RNQ as a part of COVID-19 medical management.

Acknowledgements

The authors acknowledge the authorities of Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh for approval and encouragement. Special thanks to Ayurvedic teacher and Practioner Yogi Nirwan Dev who have guided in the preparation of RNQ.

1. Liu J. et al. “Community transmission of severe acute respiratory syndrome coronavirus 2, Shenzhen, China, 2020.” Emerging Infectious Diseases vol. 26, 2020, pp. 1320–1323.

2. Chan J.F. et al. “A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.” The Lancet vol. 395, 2020, pp. 514–523.

3. Li Q. et al. “Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia.” New England Journal of Medicine vol. 382, 2020, pp. 1199–1207.

4. Chatterjee P. et al. “The 2019 novel coronavirus disease (COVID-19) pandemic: a review of the current evidence.” Indian Journal of Medical Research vol. 151, 2020, pp. 147–159.

5. Huang L. et al. “Rapid asymptomatic transmission of COVID-19 during the incubation period demonstrating strong infectivity in a cluster of youngsters aged 16–23 years outside Wuhan and characteristics of young patients with COVID-19: a prospective contact-tracing study.” Journal of Infection vol. 80, 2020, pp. e1–e13.

6. Lewnard J.A. and Lo N.C. “Scientific and ethical basis for social-distancing interventions against COVID-19.” The Lancet Infectious Diseases 2020.

7. World Health Organization. “Coronavirus disease (COVID-19) advice for the public.” World Health Organization, 2020.

8. The Lancet. “COVID-19: protecting health-care workers.” The Lancet vol. 395, 2020, pp. 922.

9. National Task Force for COVID-19 in India. “Recommendation for empiric use of hydroxychloroquine for prophylaxis of SARS-CoV-2 infection.” 2020.

10. Rajkumar et al. “Rajnirwan quath: scientific ingredients and enhancement of immunity to combat COVID-19.” International Journal of Medical Science and Clinical Research vol. 3, no. 3, 2020, pp. 388–393.

11. Rajkumar et al. “Raj Nirvan bati (a novel ayurvedic preparation) in RT-PCR positive COVID-19 cases: an interventional study.” International Journal of Medical Science and Clinical Research vol. 3, no. 3, 2020, pp. 430–440.

12. Dutta S.S. “Five per cent of all COVID-19 cases in India, till April end, were healthcare staff: ICMR report.” The New Indian Express, 2020.

13. Van Beusekom M. “Studies: 1% of healthcare workers had COVID-19.” CIDRAP, 2020.

14. Sabarwal H. “548 doctors, nurses, paramedics infected with COVID-19 across India: report.” Hindustan Times, 2020.

15. Verbeek J.H. et al. “Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff.” Cochrane Database of Systematic Reviews no. 4, 2016, pp. CD011621.

16. Pathak B.G. and Manapurath R.M. “Combating the pandemic of COVID-19 in India: health care worker perspective.” International Journal of Community Medicine and Public Health vol. 7, no. 7, 2020, pp. 2797–2802.

17. Parikh P. et al. “Protecting health-care professionals and workers (other than COVID-19 management facilities) from contamination during COVID-19 pandemic (March 26, 2020 – India).” Indian Journal of Medical Sciences vol. 72, no. 1, 2020, pp. 3–4.

18. Ehrlich H. et al. “Protecting our healthcare workers during the COVID-19 pandemic.” American Journal of Emergency Medicine vol. 38, no. 7, 2020, pp. 1527–1528. https://doi.org/10.1016/j.ajem.2020.04.024

19. Kursumovic E. et al. “Deaths in healthcare workers due to COVID-19: the need for robust data and analysis.” Anaesthesia vol. 75, 2020, pp. 989–992.

20. Lee N. et al. “A major outbreak of severe acute respiratory syndrome in Hong Kong.” New England Journal of Medicine vol. 348, 2003, pp. 1986–1994.

21. Kang L. et al. “The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus.” The Lancet Psychiatry vol. 7, 2020, pp. e14.

22. Jebur M.H. et al. “Antimicrobial effect of seed extracts, leaves and crude oil of cardamom (Elettaria cardamomum) against different types of bacteria in Hilla City, Iraq.” World Journal of Pharmaceutical Research vol. 3, no. 3, 2014.

23. Krishnamurthy K.H. “Elaa or cardamom (Elettaria cardamomum or repens).” Journal of New Approaches to Medicine and Health 2010, pp. 18.

24. Gupta S.C. et al. “Therapeutic roles of curcumin: lessons learned from clinical trials.” AAPS Journal vol. 15, 2013, pp. 195–218.

25. Mahady G.B. et al. “Turmeric (Curcuma longa) and curcumin inhibit the growth of Helicobacter pylori, a group 1 carcinogen.” Anticancer Research vol. 22, 2002, pp. 4179–4181.

26. Reddy R.C. et al. “Curcumin for malaria therapy.” Biochemical and Biophysical Research Communications vol. 326, no. 2, 2005, pp. 472–474.

27. Shukla Y. and Singh M. “Cancer preventive properties of ginger: a brief review.” Food and Chemical Toxicology vol. 45, 2007, pp. 683–690.

28. Farber L. et al. “Separation of colorants from cane sugar.” International Sugar Journal vol. 69, 1971, pp. 323–328.

29. Barocci S. et al. “Effects of some extracts on the acetylcholine release at the mouse neuromuscular joint.” Pharmacological Research vol. 39, 1991, pp. 239–245.

30. Sabina E.P. et al. “Analgesic, antipyretic and ulcerogenic effects of piperine: an active ingredient of pepper.” Journal of Pharmaceutical Sciences and Research vol. 5, no. 10, 2013, pp. 203–206.

31. Joshi D.R. et al. “A review on diversified use of the king of spices: Piper nigrum (black pepper).” International Journal of Pharmaceutical Sciences and Research vol. 9, no. 10, 2018, pp. 4089–4101.

32. Vasavirama K. and Upender M. “Piperine: a valuable alkaloid from Piper species.” International Journal of Pharmacy and Pharmaceutical Sciences vol. 6, no. 4, 2014, pp. 34–38.