• Joyce Knieff, ND, LAc

COVID-19: Improving Immunity in Pandemic Times

Let's be honest. We don't know a lot about COVID-19 in terms of treatment, prevention, and long term effects yet. It's simply too new. We can, however, take what we know about the virus now and our experiences with similar viruses, such as SARS and influenza, and extrapolate what could be useful in helping contain this pandemic.

Photo by Fusion Medical Animation on Unsplash

As mentioned in a previous post, with the virus spreading and many health care resources becoming scarce, it is important that we ration life-saving medications and medical resources for those who need it. However, this does not mean that there is nothing else for the common person to do. Besides washing your hands, disinfecting surfaces, and practicing social distancing, here are some alternative and integrative ways that may improve your immune system to protect against infection. Although nothing is certain in preventing or curing COVID-19, the mechanisms and historic use of the following give us a very good guess that they are helpful.

1. Melatonin

Melatonin is best known for its role in promoting sleep. As a supplement, it is most commonly used to correct jet lag or remedy occasional sleeplessness. However, its usefulness does not simply end there. Turns out, melatonin is a potent anti-inflammatory and antioxidant that can be used to treat cancer, diabetes, and maybe even Alzhiemer's Disease. Although melatonin does not kill the virus directly, it shows anti-viral abilities through tamping down inflammation in the body and helping out the immune system.

When COVID-19 becomes deadly, it is most often because there is too much inflammation, oxidation, and an overreaction from the immune system. This then leads to what is called a cytokine storm, which can cause acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), and then death if left untreated. Because of melatonin's many actions, including its ability to regulate the immune system, it is being proposed as a useful supplement in treating COVID-19 specifically.

In fact, it has been theorized that the reason why the novel coronavirus is so deadly in the elderly population, while not so much in children, is because children are protected by their high melatonin production.

Melatonin by age
Grivas TB, Savvidou OD. Melatonin the “light of night” in human biology and adolescent idiopathic scoliosis. Scoliosis. 2007;2:6. Published 2007 Apr 4. doi:10.1186/1748-7161-2-6

According the the graph above, children under 9 years of age have the highest amount of melatonin. This is also what we've been seeing in regards to how deadly COVID-19 can be in different ages - children under the age of 9 are the most protected, and the older you get, the more deadly the virus is.

It was also found that nine pregnant women who contracted COVID-19 and were admitted to a hospital for C-section in Wuhan all had milder symptoms. None of them got pneumonia or died, and none of their babies were infected. While the observational study didn't go into why this was, it is interesting to consider that melatonin rises dramatically in pregnant women, up to 100 fold by the third trimester when compared to healthy non-pregnant women. Could it be possible that the increased melatonin was protective for these women?

While correlation of data is not always causation, there can be a pretty good argument made about melatonin's protective effects. Moreover, melatonin is a good choice of supplement to try in this crisis also because it is a very safe supplement. Very high doses, up to several hundred times the amount your body would normally produce, have been used safely in research. That said, there are still side effects to certain dosages of melatonin use, and it is still recommended that you consult a doctor familiar with how to use it as an integrative supplement.

2. Elderberry

Although Elderberry has gotten some alarm around the internet recently for potentially contributing to cytokine storms, the studies most cited for this claim are test-tube studies. Because elderberry is a common herb that has many, many, other studies that show its ability to decrease inflammation and balance the immune system, it is more likely safe to take as a preventive herb for viral infections. It is important to remember that although elderberry can increase cytokines in the body, an increase in cytokines is absolutely necessary to defend your body against infections because they are part of your innate immune system. Moreover, while elderberry increases cytokines, it never even comes close to the level of a cytokine storm, and further increases antioxidant capacity to prevent damage to tissues as well.

Elderberry and Elderflower have had a long history in traditional and folk medicine for the prevention and treatment of respiratory infections. In fact, it is still commonly used today as a gentle and effective treatment for respiratory infections in weaker populations such as children and the elderly. In one study, it was found that patients who took an elderberry syrup after getting sick with influenza A and B felt better on an average of 4 days earlier than patients who did not take the syrup. The patients who took the elderberry syrup also didn't develop symptoms bad enough to need rescue medication during their illness.

Another study gave participants elderberry extract as prevention before boarding an international flight. This study found less of the people who took the elderberry got sick, and if they did get sick, they got better faster and their symptoms were less severe than the people who didn't take the elderberry syrup.

Given its extensive historical use and safety profile in young, old, and immune-compromised people, elderberry is another useful tool to use while we have no certain answers against COVID-19 for the time being.

3. Vitamin C

While vitamin C has long been grandma's (or mom's) go-to for immune support when you get a cold, there has long been debate on whether it is actually effective in helping out those coughs and sniffles or if it's all just placebo effect. Turns out that yes, vitamin C is quite powerful, but dosage matters.

On a basic level, vitamin C is absolutely essential for your immune system to function properly. It is very important for both innate (your immune system's first response) and adaptive (its second response) immunity to function properly. Deficiency in vitamin C causes a weakened immune system and a higher change of getting infections. In fact, in some animal studies, it was found that without vitamin C, animals infected with influenza died within a week. Those studies showed that without vitamin C, there was increased damage in the lungs due to inflammation - kind of like what we see in ARDS caused by the novel coronavirus infection.

Similar to melatonin, vitamin C has the ability to improve immune function while decreasing inflammation (they both inhibit something called NLRP3 inflammasomes, which can lead to cytokine storms). However, vitamin C seems to do this at pretty high doses. The problem with taking vitamin C by mouth, is that after you exceed 1 gram in dosage, the chance of you having loose stools goes up. This is known as the bowel tolerance of vitamin C. It is generally harmless (except for the standard risk of dehydration that comes with diarrhea), but it is quite uncomfortable. However, if you deliver vitamin C by IV means, you can deliver large doses without the gastrointestinal side effects.

While IV vitamin C has long been used in naturopathic oncology to improve outcomes in cancer patients, it has recently also been used in New York on hospitalized COVID-19 patients because it was shown to have some positive effect on COVID-19 patients in Shanghai. Although we don't know much about exactly how much effect vitamin C has in COVID-19 patients, a study on sepsis and organ failure due to severe acute respiratory failure showed that, although organ failure markers did not change super much after giving vitamin C, the patients who were given vitamin C were almost twice as likely to survive than the ones who where not.

Fowler AA 3rd, Truwit JD, Hite RD, et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial [published correction appears in JAMA. 2020 Jan 28;323(4):379]. JAMA. 2019;322(13):1261–1270. doi:10.1001/jama.2019.11825

Although it may be difficult to get as high a dose of vitamin C by taking it orally, still it may be a good nutrient to have on board, especially if your goal is to optimize your immune system while you're healthy. While taking vitamin C supplements is generally safe, if you want to taper up your dosage past 1g, it may still be prudent to work with a natural medicine practitioner to manage side effects as you go.

3. Garlic, Beets, Dark Chocolate

What do all of these foods have in common? Turns out, all of them are great at increasing the concentration of nitric oxide in your blood. While nitric oxide in the body is best known for boosting exercise performance and lowering blood pressure, turns out, it's another one of those compounds that is great at inhibiting the NLRP3 inflammasomes, effectively decreasing your inflammation while boosting your immune system.

In animal studies, it was found that garlic increased nitric oxide levels 30-40% just 15 to 60 minutes after ingestion, it was also found to help nitrc oxide become better absorbed by human cells. Beets, known in some athlete circles to help with performance and lower high blood pressure, were found to increase exhaled nitric oxide by 21.3% in humans after 45 minutes. Eating just 30 grams of dark chocolate for 15 days was also found to significantly increase nitric oxide levels and decrease blood pressure in humans.

In addition to decreasing inflammation and making the immune reaction more efficient by inhibiting NLRP3 inflammasomes, nitric oxide is also found in high concentrations in human sinuses, which may contribute to a first-line defense against bacteria and viruses that enter the nose. Nitric oxide is not only able to kill bacteria and viruses directly, it also helps our body get rid of mucus and other particles in our respiratory tracts by helping cilia (the little hairs in our respiratory tracts) move better. In fact, there is a significant amount of nitric oxide found in newborn infant sinuses, even though they aren't completely developed yet. This may help infants ward off respiratory infections in the early stages of life.

If nothing else, garlic, beets, and dark chocolate are all very healthy foods that can immediately be added to your diet. A good bonus is that all three of these foods are also showed to lower blood pressure and be generally heart-healthy. This is particularly important, because recent reports have shown that COVID-19 potentially causes heart damage and people with pre-existing cardiovascular conditions are more likely to have severe symptoms and die from the infection. In data from China, it was found that in patients who developed severe symptoms, 58% had high blood pressure and 22% had diabetes.

4. Chinese Herbs

With so much unknown about the novel coronavirus, there isn't a whole lot we can do from a western medicine front until we learn more over time. This includes developing vaccines and coming up with effective pharmaceuticals. Until then, what may be most useful is medicines that are based in an entirely different paradigm. Many in China are using Traditional Chinese Medicine based on historical use to combat COVID-19. In fact, it has been so useful thus far that many traditional formulas have been included in China's official Diagnosis and Treatment Plan of Coronavirus 2019.

Included in the Diagnosis and Treatment Plan is a formula that is recommended for confirmed cases from mild to severe symptom presentations. According to the treatment plan, this is based on the clinical observation of numerous doctors across China treating COVID-19 with Chinese herbs:

Although there aren't clinical trials or any other proper studies supporting the effectiveness of this particular formula against COVID-19 (it's all too new!) many of the herbs in the formula target symptoms that are specific for COVID-19, such as the upper respiratory symptoms and gastrointestinal symptoms.

Although there isn't much concrete data on what works specifically for COVID-19, there is a lot we can draw from the similar SARS virus from 2003. During the SARS epidemic, the fatality rate of SARS in Beijing was initially more than 52% until May 5th. However, that number dropped to 1-4% after May 20th. This was thought to be due to the use of Chinese medicine in conjunction with conventional treatment. In fact, one Hong Kong study gave an herbal formula combining the historical formulas Yu Ping Feng San (玉屏風散, Jade Windscreen) and San Ju Yin (桑菊飲, Mulberry and Chrysanthemum Combination) to high-risk hospital workers as a means to prevent SARS infection. None of the hospital staff taking this formula got infected. This was compared to a 0.4% infection rate for hospital workers who did not take the formula.

Although the amounts of the herbs were not given in the original Hong Kong study, they can be inferred from the traditional amounts in the historical formulas. Many of the herbs in both the above formulas show antiviral activity. In fact, many of them are able to inhibit the SARS virus, and in computer simulations using viral protein models, of the COVID-19 virus as well. The following chart shows the herbs that were screened in the simulations, as well as the number of antiviral actions for each herb and when best to take it during the course of disease.

Zhang DH, Wu KI, Zhang X, Feng SQ, Peng B. In silicons screening of Chinese herbal medicines with the potential to directly inhibit 2019 novel coronavirus. Journal of Integrative Medicine. 2020
Zhang DH, Wu KI, Zhang X, Feng SQ, Peng B. In silicons screening of Chinese herbal medicines with the potential to directly inhibit 2019 novel coronavirus. Journal of Integrative Medicine. 2020

Of the above, two herbs warrant particular mention, mainly because they are relatively safe, and very easy to take. These two herbs are Licorice and Astragalus. Both are sweet-tasting, easy to take, and have a very good chance of being effective against COVID-19. Both are considered Qi-tonifying herbs in Chinese Medicine, which is particularly important in terms of preventing sickness. This is because strong qi means a strong constitution that can better prevent and fight disease. While Astragalus can typically be taken in high doses in young and old, Licorice may raise blood pressure if you take too much. As such, it is usually recommended that you work with a trained herbalist especially if you already have high blood pressure.

Chinese herbal medicine can be very effective for prevention and treatment of various viral infections, but because Chinese Medicine puts heavy emphasis on the individual patient's constitution, it is still recommended that you talk to an herbalist trained in Chinese herbs in order to get a formula that will work specifically for you.

Honorable Mention: Black Tea and Pu Er tea

It turns out that a particular constituent found in black and Pu Er teas called Theaflavins is able to inhibit enzymes used by coronaviruses that cause SARS and COVID-19. However, because theaflavins are poorly absorbed, it might not help once the infection has reached the lung. It can, however, hang out at the back of your throat after you drink the tea and potentially help prevent the virus take hold in your throat. It's important to note that you may not get this preventative effect from green tea, because theaflavins are specifically created in the fermentation process that makes black and oolong teas.

Because tea-drinking is also an easy thing to incorporate into everyday life and may potentially help with prevention during this pandemic, it is worth mentioning in this article and may be worth a try in your routine.

#COVID-19 #coronavirus #SARS-CoV-2

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