Use of medicinal plants for COVID-19 prevention and respiratory symptom treatment during the pandemic in Cusco, Peru: A cross-sectional survey

TL;DR: In this paper, the authors assess factors associated with the use of medicinal plants as preventive or treatment of respiratory symptom related to COVID-19 during the pandemic in Cusco, Peru.

Abstract: BackgroundThe burden of the COVID-19 pandemic in Peru has led to people seeking alternative treatments as preventives and treatment options such as medicinal plants. This study aimed to assess factors associated with the use of medicinal plants as preventive or treatment of respiratory symptom related to COVID-19 during the pandemic in Cusco, Peru. MethodA web-based cross-sectional study was conducted on general public (20- to 70-year-old) from August 31 to September 20, 2020. Data were collected using a structured questionnaire via Google Forms, it consisted of an 11-item questionnaire that was developed and validated by expert judgment using Aikens V (Aikens V > 0.9). Both descriptive statistics and bivariate followed by multivariable logistic regression analyses were conducted to assess factors associated with the use of medicinal plants for COVID-19 prevention and respiratory symptom treatment during the pandemic. Prevalence ratios (PR) with 95% Confidence Interval (CI), and a P-value of 0.05 was used to determine statistical significance. ResultsA total of 1,747 respondents participated in the study, 80.2% reported that they used medicinal plants as preventives, while 71% reported that they used them to treat respiratory symptoms. At least, 24% of respondents used medicinal plants when presenting with two or more respiratory symptoms, while at least 11% used plants for malaise. For treatment or prevention, the multivariate analysis showed that most respondents used eucalyptus (p < 0.001 for both), ginger (p < 0.022 for both), spiked pepper (p < 0.003 for both), garlic (p = 0.023 for prevention), and chamomile (p = 0.011 for treatment). The respondents with COVID-19 (p < 0.001), at older ages (p = 0.046), and with a family member or friend who had COVID-19 (p < 0.001) used more plants for prevention. However, the respondents with technical or higher education used less plants for treatment (p < 0.001). ConclusionThere was a significant use of medicinal plants for both prevention and treatment, which was associated with several population characteristics and whether respondents had COVID-19.

Summary

Introduction

• COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11 , 2020 because of its rapid transmission and infection rates worldwide (1, 2) .
• This disease is characterized by a progressive and severe pneumonia, and the most common symptoms are fever, dyspnea, dry cough, fatigue, headache, anosmia, and ageusia (2) (3) (4) .
• Furthermore, Peru has reported discrepancies in the official reports of COVID-19 deaths nationwide (16) , poor execution of SARS-CoV-2 testing and reporting (17) , and an increase number of COVID-19 cases in children and adolescents (7, 18) .
• Therefore, it has been reported that some people resource to self-medication (20) and others to the use of medicinal plants (21) as potential but unproven methods to ameliorate and/or prevent symptoms related to COVID-19.
• In Latin America, the Regional Office of WHO for the Americas (AMOR/PAHO) indicates that 71% and 40% of the population of Chile and Colombia, respectively, use traditional medicine (35, 36) .

Ethical considerations

• The survey was approved by the San Antonio Abad del Cusco National University ethics committee (#007-2020-CBI-UNSAAC).
• The participants remained anonymous and had the option to finish the survey at any time, and their information was kept confidential.
• All the survey participants were well-versed on the study intentions and were required to consent before the enrollment.
• The participants were not involved in any of the planning, execution and reporting stages of the study.

Study design

• After including the experts' observations, a pilot study was performed (from August 16 to 4) with 336 respondents in in five districts of Cusco, Peru.
• The actual survey consisted of an online questionnaire that was sent via WhatsApp, Messenger, and Facebook.
• The authors surveyed general public who were adults of both genders aged 20 to 70 years in five districts of Cusco, Peru with high-risk COVID-19 transmission according to the Epidemiological Alert AE-017-2020 (44) .
• The five districts were Cusco, San Jerónimo, San Sebastián, Santiago, and Wanchaq.

Outcomes and Covariates

• The survey (Annex 1) included 11 questions, 5 were demographic questions.
• Then, the respondents were asked if they were diagnosed with COVID-19, and if any family member or friend was diagnosed with COVID-19.
• The respondents were asked to select from a list of 17 selected medicinal plants the ones they have used to prevent or treat COVID-19 related respiratory symptoms.
• The symptoms included cough, sore throat, fever, headache or malaise.
• The selected symptoms relate to the most common COVID-19 symptoms reported by the Center of Disease Control and Prevention (CDC) (45) .

Statistical analysis

• Data analysis was done in STATA version 14 (Stata Corp) with a significance level set at p<0.05.
• Descriptive analysis of categorical variables was performed to show the frequency and percentage of each response.
• The results were summarized in unidimensional tables to identify the medicinal plants that are most used by the respondents.
• Generalized linear models were used in the multivariate analysis using the Poisson family, the log-link function, and the models for variances of robust models and the district of residence as a cluster, thereby obtaining the prevalence ratios (PR).
• The 95% confidence intervals (CI) and p-value < 0.05 were considered as the limit of statistical significance.

Medicinal plants used and respiratory symptoms associated with their use as treatment options

• The most frequently used medicinal plant was eucalyptus followed by ginger, garlic, spiked pepper, chamomile and coca.
• It was observed that all the medicinal plants were used for 2 or more respiratory symptoms.
• The bivariate statistics showed that the use of medicinal plants was associated with the occurrence of two or more symptoms (24-51%), followed by malaise (11-41%).

Multivariate analysis of the factors associated to the use of medicinal plants

• Therefore, eucalyptus, spiked pepper, ginger, and chamomile were the most used for the treatment of respiratory symptoms, whereas panty and wira wira were the least used.
• There was also a positive association between the respondents diagnosed with COVID-19 and the use of medicinal plants for treatment (PR: 1.22, 95% CI: 1.11-1.34, p < 0.001); precisely, those with COVID-19 used more medicinal plants for prevention.

DISCUSSION

• Regarding the prevention of COVID-19 respiratory symptoms, this study showed that 80.2% of the population of Cusco, Peru, used medicinal plants for this purpose.
• This correlates to previous studies where women are more versed in the properties of medicinal plants (53) and that they typically use medicinal plants to take care of the health of their family members (54, 55) .
• This could potentially be riskier for patients with COVID-19.
• It needs to be acknowledged that the ethnopharmacological use of medicinal plants for prevention or treatment of respiratory symptoms related to COVID-19 still needs to be evaluated in clinical settings in order to have solid evidence of their effectiveness and to isolate compounds with potential pharmacological use.

LIMITATIONS OF THE STUDY

• The limitations of this study included the fact that the results cannot be extrapolated to the entire Peruvian population.
• The objective of this study was to determine the association between the use of medicinal plants and the treatment or prevention of respiratory symptoms in the population of the five districts of Cusco, one of the most important cities in Peru.
• This study is the first to investigate this association in this population; therefore, this could become a basis for other studies that could cover a larger population from all over the country.
• Another limitation is bias occurred as a result of the cross-sectional study design to determine definitive cause and effect associations.
• Similarly, the responders performed a self-reported assessment in an online data collection platform, which could lead to under or over-reporting and the data collector has not ability to verify or validate.

CONCLUSION

• The current study reported an association between the use of medicinal plants and the treatment or prevention of the respiratory symptoms related to COVID-19, and the most used plants were eucalyptus, ginger, chamomile, and garlic.
• Moreover, it was determined that the study population used a greater number of plants for disease prevention when the respondent was older and if they or a friend or family member had contracted COVID-19.
• The p-values were obtained based on the chi-square test.

Figures

Table 1. Socio-demographic characteristics of respondents that used medicinal plants for the treatment or prevention of respiratory symptoms during the COVID-19 pandemic in Cusco, Peru.

Table 4. Multivariate analysis of the use of medicinal plants for the treatment or prevention of respiratory symptoms during the COVID-19 pandemic in Cusco, Peru

Full text

Use of medicinal plants for COVID-19 prevention and respiratory symptom
treatment during the pandemic in Cusco, Peru: A cross-sectional survey
Magaly Villena-Tejada
1*
, Ingrid Vera-Ferchau
1
, Anahí Cardona-Rivero
1
, Rina Zamalloa-
Cornejo
1
, Maritza Quispe-Florez
1
, Zany Frisancho-Triveño
1
,
Rosario C. Abarca-
Melendez
1
, Susan G. Alvarez-Sucari
1
, Christian R. Mejia
2
, Jaime A. Yañez
3,4
*
1. Universidad Nacional de San Antonio Abad del Cusco. Cusco. Peru.
2. Translational Medicine Research Centre. Universidad Norbert Wiener. Lima,
Peru.
3. Universidad Peruana de Ciencias Aplicadas, Facultad de Educación, Carrera de
Educación y Gestión del Aprendizaje, Lima, Peru.
4. Gerencia Corporativa de Asuntos Científicos y Regulatorios, Teoma Global, Lima,
Peru.
*Corresponding Authors:
Magaly Villena-Tejada
Universidad Nacional de San Antonio Abad del Cusco. Cusco. Peru.
Email: magaly.villena@unsaac.edu.pe
Jaime A. Yáñez, PhD
Universidad Peruana de Ciencias Aplicadas, Facultad de Educacion, Carrera de
Educacion y Gestion del Aprendizaje, Lima, Peru.
Email: jaimeayanez@gmail.com
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 30, 2021. ; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

ABSTRACT
Background: The burden of the COVID-19 pandemic in Peru has led to people
seeking alternative treatments as preventives and treatment options such as medicinal
plants. This study aimed to assess factors associated with the use of medicinal plants
as preventive or treatment of respiratory symptom related to COVID-19 during the
pandemic in Cusco, Peru.
Method: A web-based cross-sectional study was conducted on general public (20- to
70-year-old) from August 31 to September 20, 2020. Data were collected using a
structured questionnaire via Google Forms, it consisted of an 11-item questionnaire
that was developed and validated by expert judgment using Aiken's V (Aiken's V > 0.9).
Both descriptive statistics and bivariate followed by multivariable logistic regression
analyses were conducted to assess factors associated with the use of medicinal plants
for COVID-19 prevention and respiratory symptom treatment during the pandemic.
Prevalence ratios (PR) with 95% Confidence Interval (CI), and a P-value of 0.05 was
used to determine statistical significance.
Results: A total of 1,747 respondents participated in the study, 80.2% reported that
they used medicinal plants as preventives, while 71% reported that they used them to
treat respiratory symptoms. At least, 24% of respondents used medicinal plants when
presenting with two or more respiratory symptoms, while at least 11% used plants for
malaise. For treatment or prevention, the multivariate analysis showed that most
respondents used eucalyptus (p < 0.001 for both), ginger (p < 0.022 for both), spiked
pepper (p < 0.003 for both), garlic (p = 0.023 for prevention), and chamomile (p = 0.011
for treatment). The respondents with COVID-19 (p < 0.001), at older ages (p = 0.046),
and with a family member or friend who had COVID-19 (p < 0.001) used more plants
for prevention. However, the respondents with technical or higher education used less
plants for treatment (p < 0.001).
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 30, 2021. ; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprint

Conclusion: There was a significant use of medicinal plants for both prevention and
treatment, which was associated with several population characteristics and whether
respondents had COVID-19.
Keywords: medicinal plants, COVID-19, prevention, treatment, respiratory symptoms,
pandemic, Peru.
Introduction
COVID-19 was declared a pandemic by the World Health Organization (WHO) on
March 11, 2020 because of its rapid transmission and infection rates worldwide (1, 2).
This disease is characterized by a progressive and severe pneumonia, and the most
common symptoms are fever, dyspnea, dry cough, fatigue, headache, anosmia, and
ageusia (2-4). As of May 11, 2021, more than 159 million global confirmed cases and
more than 3 million deaths have been reported (5). The first confirmed case in Peru
was reported on March 8, 2020 (6), and the number of cases rapidly increased despite
the measures established by the Peruvian government (7, 8). In less than four months,
Peru ranked second among Latin American countries, following Brazil, for the highest
number of COVID-19 cases and deaths (9, 10). Multiple publications have illustrated
the fragmented healthcare system in Peru, which has not been the most effective
during the COVID-19 pandemic resulting in a high number of physicians’ deaths (11),
limited public policies (12), and detrimental effects in the mental status of the
population (13-15). Furthermore, Peru has reported discrepancies in the official reports
of COVID-19 deaths nationwide (16), poor execution of SARS-CoV-2 testing and
reporting (17), and an increase number of COVID-19 cases in children and adolescents
(7, 18).
The current pandemic generates fear in the population who seek solutions to
prevent or alleviate the symptoms of the disease since they feel the only resource
available to the is to self-help, self-care and self-medicate (19). Therefore, it has been
reported that some people resource to self-medication (20) and others to the use of
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 30, 2021. ; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprint

medicinal plants (21) as potential but unproven methods to ameliorate and/or prevent
symptoms related to COVID-19. The Ministry of Health in Peru published the
symptomatic pharmacological treatment options for COVID-19 to control the pandemic
(22). These options included the clinical use of hydroxychloroquine and ivermectin for
mild cases of COVID-19 and hydroxychloroquine plus azithromycin and/or chloroquine
phosphate plus ivermectin for moderate and severe cases of COVID-19 (6, 22).
However, this recommendation led to self-medication reports in Peru (6, 20), which
also gets accompanied with the use of medicinal plants. This practice has become
increasingly common in Peru as panic spread in the general population, who anxiously
wait for positive news about the prevention, treatment and vaccination (20).
The idiosyncrasy of the population has also focused on the use of medicinal plants,
natural products or preparations, with antiviral and anti-inflammatory properties to
strengthen the immune system or treat respiratory diseases (23). Countries, such as
China, India, Bolivia, Morocco, Nepal, Peru and Brazil, are using traditional medicine
against COVID-19 (23-32). There are approximately 50,000 plant species with
medicinal uses, and the WHO has estimated that 80% of the population of developing
countries use traditional medicine as their main source of medicines (33). In Europe,
the clinical use of medicinal plants is approved under the directive 24/2004 for the
treatment of colds (34); these treatments are accessible and available. In Latin
America, the Regional Office of WHO for the Americas (AMOR/PAHO) indicates that
71% and 40% of the population of Chile and Colombia, respectively, use traditional
medicine (35, 36). In Peru, a megadiverse country, the use of medicinal plants for the
treatment of various conditions, such as malaise and gastrointestinal and respiratory
diseases, dates from the Inca period (24, 36-39), and currently approximately 1,400
species are used for medicinal purposes in both native and urban communities (24,
36). It comes as no surprise that traditional medicine is currently being used by the
Peruvian population in the context of the COVID-19 pandemic. Thus, the objective of
this study was to assess factors associated with the use of medicinal plants as an
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 30, 2021. ; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprint

adjuvant for the treatment or prevention of respiratory symptoms during the COVID-19
pandemic in Cusco, Peru.
METHODS
Ethical considerations
The survey was approved by the San Antonio Abad del Cusco National University
ethics committee (#007-2020-CBI-UNSAAC). The participants remained anonymous
and had the option to finish the survey at any time, and their information was kept
confidential. All the survey participants were well-versed on the study intentions and
were required to consent before the enrollment. The participants were not involved in
any of the planning, execution and reporting stages of the study.
Study design
We conducted an online cross-sectional multicenter survey, which was initially
evaluated by 10 expert judges using Aiken's V (40). After including the experts’
observations, a pilot study was performed (from August 16 to 4) with 336 respondents
in in five districts of Cusco, Peru. The pilot data was used to calculate the minimal
sample size necessary for the actual study. It was determined that a minimum sample
size of 1,530 was necessary to achieve a minimum percentage difference of 2.5%
(49.0% versus 51.5%), a statistical power of 80%, and a confidence level of 95% (data
not shown). The sample size was calculated using power analysis (41).
The actual survey consisted of an online questionnaire that was sent via
WhatsApp, Messenger, and Facebook. The shared questionnaire was made
anonymous ensuring data confidentiality and reliability. The survey was performed from
August 31 to September 20, 2020 after approximately 9 months of lockdown and social
distancing measures in Peru due to the COVID-19 outbreak. At the beginning of the
survey (August 31) the number of COVID-19 confirmed cases was 652,037 and 28,944
deaths (42), while at the end of the survey (September 20) the confirmed cases
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 30, 2021. ; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprint

Frequently asked questions

Q1. What have the authors contributed in "Use of medicinal plants for covid-19 prevention and respiratory symptom treatment during the pandemic in cusco, peru: a cross-sectional survey" ?

This study aimed to assess factors associated with the use of medicinal plants as preventive or treatment of respiratory symptom related to COVID-19 during the pandemic in Cusco, Peru. A web-based cross-sectional study was conducted on general public ( 20to 70-year-old ) from August 31 to September 20, 2020. Results: A total of 1,747 respondents participated in the study, 80. 2 % reported that they used medicinal plants as preventives, while 71 % reported that they used them to treat respiratory symptoms. It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

Q2. What countries are using traditional medicine against COVID-19?

such as China, India, Bolivia, Morocco, Nepal, Peru and Brazil, are using traditional medicine against COVID-19 (23-32). 

Q3. What are the main symptoms of COVID-19?

COVID-19 symptoms develop with inflammation and hemotoxicity, which could suggest that blood-purifying plants with anti-inflammatory, antioxidant, and antiviral properties could be considered as candidates for the treatment of COVID-19 (62). 

Q4. What are the commonly used medicinal plants for the treatment of respiratory symptoms?

eucalyptus, spiked pepper, ginger, and chamomile were the most used for the treatment of respiratory symptoms, whereas panty and wira wira were the least used. 

Q5. What is the main effect of jensenone on SARS-CoV-2?

it has been reported that jensenone, a compound obtained from the essential oil of eucalyptus exhibits antiviral effect against the main protein of SARS-CoV-2 (61). 

Q6. What is the main effect of the study on the use of medicinal plants?

Regarding the prevention of COVID-19 respiratory symptoms, this study showed that 80.2% of the population of Cusco, Peru, used medicinal plants for this purpose. 

Q7. What is the main effect of the use of medicinal plants on the respiratory symptoms of COVID?

This includes the use of medicinal plants, which were revalued during this pandemic to manage the COVID19 symptoms, because plants are a source of plant metabolites with antiviral activity (49). 

Q8. What is the role of probiotics in the treatment of respiratory symptoms?

it has been reported that diet supplementation with probiotics and nutraceuticals play a fundamental role in the treatment of respiratory symptoms, because many products produce an immune response to respiratory viruses in addition to their regulatory activity for the inflammation caused by COVID-19 (50). 

Q9. What is the author's opinion on the preprintor?

; https://doi.org/10.1101/2021.05.26.21257890doi: medRxiv preprintor treatment of respiratory symptoms related to COVID-19 still needs to be evaluated in clinical settings in order to have solid evidence of their effectiveness and to isolate compounds with potential pharmacological use. 

Q10. How many cases of COVID-19 have been reported in Peru?

In less than four months, Peru ranked second among Latin American countries, following Brazil, for the highest number of COVID-19 cases and deaths (9, 10).