COVID19 Clinical Presentations and Herbal Self-Medication Reported Practice Among Sudanese Patients, 2021

Background: after emerging of covid 19 pandemic from China with high rate of spreading and transmission through respiratory droplets, without recognized therapy a lot of people worldwide use herbs in attempt to help their body overcome the disease, and Sudanese people were not an exception.

Methods: A cross-sectional population-based online survey was done targeting those who experienced COVID-19 among Sudanese through an online internet-based questionnaire distributed on social media platforms (mainly Facebook and WhatsApp). Descriptive statistics used to summarize data and presented using frequency tables. Chi square test was used to determine association among categorical variables. All statistical tests were considered significant when p value =or< 0.05.

Results: 204 responses received from COVID-19 former and active cases. Cough and shortness of breath were reported by 52.7% and 59.3% of the respondents respectively. Fever recognized in more than two thirds (68.1%), and joint and muscle pain was the commonest symptom reported by 79.9% of participants. All the respondents reported using traditional herbs or plants for cure. Citrus plants like lemon, orange and grape fruits, were the commonest, used by 94%, followed by the local herbs, acacia (65%), ginger (56%) and baobab-fruit (46%). An adjusted analysis found that being an obese was associated with higher hospital admission, while using herbs have no effect on hospital admission, overall, less than 7.4% of the participants admitted to hospital.

Conclusions: Almost all affected persons used herbs for cure beside other treatment. The most commonly used herbs were citrus (lemon, orange and grape), and few used cinnamon and other herbs, with no significant effect on disease severity was detected.

In December 2019, an increase in cases of patients with pneumonia of unknown etiology emerged in Wuhan, a large city of 11 million people in central China [1]. The pathogen was soon identified as a novel coronavirus which share more than 79% of its sequence with coronavirus of severe acute respiratory syndrome (SARS-CoV) [2]. The novel virus was named as SARS-CoV-2 and its infection announced by WHO as coronavirus disease 2019 (COVID-19) [3]. The virus has rapid spread, the infection extended to most parts of the world with more than 81.2 million cases and 1.77 million deaths by December 29, 2020 [4]. Infection occurs mainly through exposure to respiratory droplets when a person is in close contact (within 6 feets) with someone who has COVID-19. It can spread sometimes by airborne transmission, and less commonly through contact with contaminated surfaces, and rarely spread between human and animals [5]. COVID-19 has no recognized specific therapeutic agent, however, the efforts of developing curing antiviral agents are ongoing. The main care provided to infected people is supportive, with fluids vitamins and minerals, and more advanced oxygen and respiratory support to severe cases.

As for other illnesses, and although most of them still not well studied, people also used foods and herbal recipes to help their body overcome the disease. Herbs are known for their anti-inflammatory, antioxidant, antimicrobial   antimutagenic, and anticancer effects [6] Some countries even officially added herbal formulae to their treatment guidelines, for instance, in China there are 13 herbal formulae recommended for treatment of COVID19 [7].  in Africa, a country like Nigeria that is known for its vulnerability and law health system capacity, had earlier announced and recommended the use of medicinal plants that are known for their immune boosting, detoxification and anti-oxidation effects [8]. In Sudan medicinal plants and herbs are widely spread and used by communities in different forms. These traditional remedies represent an important part of Sudanese life and are available for the majority of the population [9]. Sudanese use medicinal plant for a wide range of conditions including respiratory, gastrointestinal, skin conditions, malaria and even diabetes [10]. This study describes the use of herbs by COVID19 infected patients and try to identify a possible role in cure or lowering the intensity of the illness.

A cross-sectional population-based survey was done targeting those who experienced COVID-19 among Sudanese. It was an online internet-based survey included those who were previously infected with novel corona virus, within 3 months before the study, or those with active disease. Using convenient sampling technique, the sample size was calculated to be 384 by the formula n = z2 * (pq)2/e2. An administered questionnaire was developed and transformed into a Google online form. Then it was distributed through social media platforms (mainly Facebook and WhatsApp). The Data then cleaned, coded and analyzed using the Statistical Package for the Social Science (SPSS) software, version 22. Description was done using frequency tables and cross tables. Statistical associations were tested and multivariate logistic regression was also conducted. Each participant was required to read a written informed online consent and agree to participate before filling the online form. 

A total of 204 participants responded to the questionnaire and stated they were either active or recovered COVID-19 case within 3 months before the study. The majority of patients (79.9%) had joint and muscle pain, the fewest had painful swallowing (32.8%) (table 1).

Table 1: shows frequency of symptoms and signs of COVID 19 Sudanese patients, 2021. (n = 204)

An adjusted analysis found that being obese was associated with higher hospital admission (aOR: 12.932; 95%CI: 1.01, 16.00, p = 0.049). Having diabetes (aOR: 0.042; 95%CI: 0.006, 0.296, p=.001) and asthma (aOR: 0.092 (95%CI: 0.023, 0.370, p = .001) were associated with less hospital admission (table 2).

Table 2: adjusted logistic regression analyses showing factors associated with hospital admissions of COVID-19 patients in Sudan, (n = 204).

Regarding using herbs for self-medication as appearing in figure 1, nearly all patients (94%) used citrus (lemon, orange and grape), but few used cinnamon and other herbs (17%).

Figure 1: Different types of herbs used in treatment of covid 19 by Sudanese COVID19 patient (n = 204)

Adjusted analysis revealed that using different types of herbs has no effect on hospital admissions (table 3). 

Table 3: adjusted logistic regression analyses showing herbals affecting hospital admissions of COVID-19 patients in Sudan, (n = 204).

Regarding the clinical presentations, the study identified cough and shortness of breath in more than half of the respondents with the fever recognized in more than two thirds. These are the commonest symptoms of COVID19 reported by many studies, for instance, Ning Jiang et al 2021 concluded that in their study in China [11]. Other common features observed were joint and muscle pain. loss of smell and taste was recognized in the majority of the respondents (68%), this is a specific symptom for COVID19 that lately included in the WHO case definition of the probable case [12]. 

The comorbidities identified were diabetes, hypertension, asthma, cardiac diseases and renal diseases. This might be explanatory to the getting COVID-19 infection, as these conditions increase the susceptibility of individuals [13]. Interestingly, when modeling, adjusted logistic regression, was done, being diabetic or asthmatic was associated with a lower rate of hospitalization. This could be attributed to the non-representative sample, as diabetes and asthma were known factors for the severe disease [14]. The study identifies obesity as a risk factor severity of illness as obese patients were several times more likely to be hospitalized (aOR: (12.932 (1.01 - 16.0)). This is also reported by Antonio Gimeno-Miguel et al study [13].

Herbs are generally used for treatment and cure for several condition as reported by many Studies, like Magaly Villena-Tejada et al study [15]. The use of local herbal remedies for treatment, especially for respiratory illnesses is known among Sudanese people [9]. Most of the respondents (94%) used citrus (lemon, orange, and grapefruit), majority of them received local remedies containing acacia and ginger. Other studies reported that ginger was the most frequently used herbs for covid 19 infection [16,17]. Cinnamon was also used by (17%) of participants, evidence in 2021 highlighted the anti-inflammatory and antiviral effect of cinnamon and also reported its use to treat COVID-19 [18,19]. 

To assess the effect of herbal use on the severity of the disease, an adjusted analysis was done and no effect on hospital admissions detected. This could by due to the limited sample size, a well-designed study recommended to dig more in this area. In contrast, Aleksander Gajewski et al. and others declared that some herbs significantly reduce hospitalization rates and the COVID-19 symptoms [13,20]. Furthermore, the Chilot Abiyu Demeke et al. study shows that herbal use improves clinical symptoms, reduces mortality, and reduces the virus's recurrence rate [21]. According to a study conducted by Leen A. Aldwihi et al., the use of herbal medicine significantly reduces hospitalization rates [13]. We recommend further researches on the topic as Sudan is rich with many types of herbal plants that are used for COVID-19 and other illnesses.

Limitations

In ability to achieve the targeted sample size.

Patients reported clinical picture aligned with what is known about the COVID-19. The study reported the practice of herbal use during pandemic in Sudan. Almost all affected persons used herbs for cure. The most commonly used herbs were citrus (lemon, orange and grape), and few used cinnamon and other herbs.  No significant association was detected between use of herbs and the severity of the disease in terms of admission. More studies are recommended for better understanding of the medicinal effects of herbal plants used in Sudan. 

Author's contributions

A.I.; conceptualization and methodology, A.A. and M.M.; software, S.A. and M.M. and A.H..; formal analysis, W.Y. and M.A. and M.H. and Ma.M.; resources, A.H. and A.I. and S.A.; writing—original draft preparation, A.I. and M.M.; writing—review and editing, E.M.; supervision. 

Funding

This research received no external funding.

Conflict of interest

The authors declare that they have no conflict of interest.

Data Availability

The data used in this study are available from the corresponding author on reasonable request.