ShelbyLaneMD

3.17.20

COVID 19:    Choices For Nutritional Support/Treatment and Prevention

As a preventative medicine physician, I get questions every day about what can I do to protect me, my family and my loved ones from COVID19.  After researching multiple resources, and there are thousands, I found the following article to be very useful.

As the COVID19  (CORONA VIRUS) pandemic spreads, people want to know what can I do to protect my immune system and that of my loved ones.  There is no specific treatment and no vaccine, as of this date.  The government and health officials are acting as fast as they can to provide testing, develop a vaccine and provide treatment.  Current recommendations include hand washing, covering your mouth, social distancing, self-quarantine and staying home if you are sick.  All good. Stop coughing in people's faces. NO. NO.

So the next question is,  what nutritionals have any benefit and how should you take them? 

The following is informational about nutritional therapies and you should always seek the care and advice of your doctor or health care professional.

REMEMBER to protect yourself and your immune system by following the CDC guidelines that are updated on a daily basis.

Best of health.  Remember to be KIND and SMILE.  Watch a good comedy and laugh.

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What You Need to Know About COVID-19

Written by Ross Bailey, BKin, MKin

Reviewed by Dr. Alex Keller, ND

On December 31st, 2019, the first case of the Current Novel Coronavirus Disease 2019, or COVID-19, was reported in Wuhan, China. (125) Though the term "novel" may seem to imply that this coronavirus is a previously undiscovered infectious virus, coronaviruses actually encompass a large family of known viruses that can infect animals and humans. SARS-CoV-2 (or Severe Immune Respiratory Syndrome-Coronavirus-2), specifically, is the name of the most recent virus that has spread on a global scale. (125)

Since the diagnosis of the first case of COVID-19, the number of infections has spread worldwide. As of March 13th, 2020, approximately 132,536 cases had been identified in 123 countries across the globe. In the United States and Canada, 1264 and 138 cases have been confirmed, respectively. (126)

To monitor the number of cases worldwide and by country, the World Health Organization (WHO) has provided a global map with rolling updates on the number of cases.

What is SARS-CoV-2?

SARS-CoV-2 is a type of virus belonging to the family of coronaviruses. Coronaviruses cause respiratory disturbances as mild as the common cold or more severe respiratory conditions, which can result in death. Other notable, fatal viruses belonging to this family include the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV). (57)(124) Examples of less potent coronaviruses include Human coronavirus NL63 (HCoV-NL63), Human coronavirus 229E (HCoV-229E), Human coronavirus OC43 (HCoV-OC43), and Human coronavirus HKU1 (HKU1), which can cause mild respiratory conditions in individuals with healthy immune function. (25)

Severe cases of COVID-19 may be fatal in specific populations. As of March 13th, 2020, 4947 deaths have been reported, 36 of which were in the United States and one in Canada. (126) Populations with the greatest risk of mortality include the elderly and individuals with other underlying chronic illnesses, such as heart disease, diabetes, or lung disease. (18)(97) Similarly to SARS-CoV and MERS-CoV, infants and children do not seem to have increased susceptibility to COVID-19 and symptoms are typically milder than in adults. (16)

COVID-19 signs and symptoms

As with other coronaviruses, signs and symptoms of COVID-19 are typically mild and present similarly to the common cold or flu in most people. (93) The incubation period (the time between infection and the point at which symptoms occur) is estimated to be between three to six days, symptoms most often occurring by day five. (20)(127) Symptoms typically continue to persist and increase in severity for approximately 14 or more days, at which point the need for admission to intensive care units may become necessary.

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Signs and symptoms of COVID-19 are typically mild and present similarly to the common cold or flu in most people.

Signs and symptoms of the illness may include the following:

* Fever

* Cough

* Fatigue or myalgia

* Sputum

* Dyspnea

* Leucopenia or lymphopenia

* Acute respiratory distress syndrome

* Pneumonia with abnormal CT images (57)(127)

It is important to note that patients who are asymptomatic can still carry and transmit the virus. (56)

How is COVID-19 transmitted?

Alphacoronaviruses and betacoronaviruses (including SARS-CoV-2, SARS-CoV, and MERS-COV) are capable of infecting mammals. Bats and rodents are believed to be the natural hosts of coronaviruses, though these can be transmitted to other intermediary mammals, such as civets and camels, before transmission to humans. (25) Hong Kong's Agriculture, Fisheries and Conservation Department (AFCD) reported a mild case of COVID-19 in a dog belonging to an infected patient, (116) however, there is currently no evidence that dogs can transmit the virus to humans. (128)

Most evidence indicates that COVID-19 is primarily transmitted between humans. (20)(57) Similar to the transmission of SARS-CoV and MERS-CoV, the main route by which SARS-CoV-2 is transmitted between individuals is via respiratory droplets. Contact with these droplets and subsequent touching of eyes, nose, or mouth can lead to transmission. Aerosols or fomites (objects that can carry the virus such as keyboards, clothes, or utensils) may also play a secondary role in transmission. (97)(99)

While respiratory liquid, such as through coughing or sneezing, may be the primary route of transmission, it is possible that the infection becomes systemic, as was observed with SARS-CoV, and other routes of transmission could be discovered. (99) There has been evidence of the virus in the blood and fecal matter of patients not presenting positive diagnoses from oral swabs. (135) However, the risk of transmission through fecal matter remains secondary to exposure to respiratory liquids. (127)

When might a practitioner recommend SARS-CoV-2 testing?

With global news coverage on the increasing number of deaths worldwide, many practitioners and patients may rush to testing at the first sign of symptoms.

However, the Centres for Disease Control and Prevention (CDC) recommends that practitioners exercise clinical judgment before testing for SARS-Cov-2, taking into consideration the clinical course of the infection and the epidemiology (the incidence, tracking, and management) of the virus. (15)

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The checklist above summarizes the CDC's recommended guide for evaluating the need for SARS-CoV-2 diagnostic testing. (15)

Current COVID-19 treatment approaches

As of March 4th, 2020, the CDC has indicated that there is no vaccine or specific treatment to cure COVID-19. Current guidelines are meant as supportive care. (15) Management of the infection primarily includes controlling and preventing further spread of the virus, and assistive care for symptoms and other complications including organ support if needed. (17)

Protecting yourself and others from COVID-19

Protecting yourself and others from COVID-19 primarily consists of lifestyle approaches that center on reducing the risk of exposure to viral infection. The CDC recommends the following:

* Avoiding contact with infected individuals

* Avoiding touching of the face

* Remaining at home if you have signs and symptoms

* Using disposable tissues to catch sneezes or coughs

* Not reusing disposable tissues that have caught sneezes or coughs

* Regularly disinfecting households

* Regularly washing hands (see the CDC's proper handwashing technique video)

* Wearing a facemask ONLY if showing signs of COVID-19, or if working in health care settings (19)

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Wash your hands regularly to help reduce your risk of exposure to viral infection.

General recommendations to support immune function for the prevention of viral infections

Foods for immune support

Maintaining a healthy and balanced diet is intricately connected to proper immune function. (24) There are several food sources that contain anti-oxidant and anti-viral properties that may assist in providing immune system support.

Anti-oxidants prevent or reduce oxidative stress that is associated with most chronic diseases. Anti-oxidants can contribute to cellular maintenance, DNA repair, and longevity. Foods with the highest anti-oxidant profiles include berries, fruits, nuts, chocolate, and vegetables. Plant-based foods including spices and herbs also contain high proportions of anti-oxidants. (11)

Incorporation of herbs and spices into the diet is another way to ingest foods that have demonstrated anti-viral properties. Namely, immune-supportive herbs or their active components, which can be found in other natural products such as supplements, and may specifically target coronaviruses include:

* Artemisia annua (sweet wormwood)

* Houttuynia cordata (chameleon's plant)

* Isatis indigotica (dyer's woad)

* Lindera aggregata (evergreen, spice bush)

* Lycoris radiata (red spider lily)

* Pyrrosia lingua (felt fern)

* Torreya nucifera (Japanese nutmeg-yew)

* Myricetin, saikosaponins or scutellarein (78)

Top 12 supplements for immune support for viral infections

The following provides a list of supplements that have been used as immune system support for viral infections.

1. Vitamin C

Vitamin C is one of the most popular immune support vitamins when it comes to the common cold and flu. Systematic reviews and meta-analyses indicate that supplementation with a minimum of 200 mg in children and 1 g of vitamin C per day in adults may be used as an ongoing maintenance dose to boost immunity. Increasing the dose to 1 to 2 g in children and 3 to 4 g in adults at the onset of common cold symptoms can reduce the duration of infection. This may be a result of increased anti-microbial, and immune cell activities, as well as improved anti-oxidant capacity. (51)(105)

2. Quercetin

Quercetin, a flavonoid found in many plant-based foods, has also shown efficacy in reducing the incidence and severity of upper respiratory tract infection (URTI) symptoms. A dose of 1000 mg per day has been shown to reduce the severity of URTI symptoms as well as the number of sick days, particularly for adults over the age of 40. (48). The same dose over two weeks also reduced the incidence of URTIs in trained athletes. (91)

A derivative molecule of quercetin, quercetin 3-β-O-d-glucoside has been shown to provide protection against ebola viruses in mice and in vitro. (104) Several other studies in vitro studies have demonstrated anti-viral properties against Influenza, Mayaro, Chikungunya, Epstein-Barr, and Hepatitis C viruses. (33)(65)(67)(71)(73)

Several studies also suggest that the combination of vitamin C and quercetin can provide synergistic effects for immune-boosting activity by reducing oxidative stress, and DNA damage. (3)(92)(98)

3. Elderberry

Black elderberry (Sambucus nigra) contains various bioactive constituents such as anthocyanins, which have been shown to have anti-viral and immune-stimulating properties. A 2019 meta-analysis showed that elderberry supplementation substantially reduced the symptoms of viral URTIs, particularly for the influenza virus. (47)

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Black elderberry has been shown to have anti-viral and immune-stimulating properties.

Dosing and administration protocols have varied between published trials, but consistently improve symptoms of cold and flu, and reduce the duration of infection. Two trials have shown efficacy with the administration of 15 ml (1 tablespoon) of an elderberry standardized extract syrup, four times per day to adults during meals for three to five days while children use half doses. (132)(133) Another study used slow-dissolving lozenges containing 175 mg of a proprietary elderberry extract, four times per day with meals and before bed, over two days. (70) Finally, proprietary extract capsules containing 300 mg of elderberry extract has been provided as two capsules per day for ten days prior to air-travel, and three capsules for four to five days at the destination have been used. (118)

4. Goldenseal

Goldenseal (Hydrastis canadensis) has been traditionally used as an anti-infectious ingredient, and now used in supplements for colds and respiratory tract infections, however, there is a current lack of human clinical trials using the whole plant or an extract. (90)

Goldenseal has been shown to inhibit the growth of influenza A and inflammatory markers in vitro. (14) It has also demonstrated anti-microbial activity against methicillin-resistant Staphylococcus aureus and Helicobacter pylori in vitro, which are two pathogenic bacteria responsible for the development of a variety of health conditions. (13)(27) Goldenseal may also modulate the anti-inflammatory and pro-inflammatory response as it may reduce the production of inflammatory biomarkers such as TNF-?, interleukin IL-6, IL-10, and IL-12 from macrophages. (23) In rats, goldenseal also increased immunoglobulin M (IgM) response within two weeks of use. (106) IgM is produced in response to antigens and may protect against viral infections including influenza. (8)

One of the constituents of goldenseal, berberine, has also demonstrated anti-viral properties. In the lung cells of mice, berberine inhibited influenza virus replication and reduced the virus-induced alteration of immune cell ratios and rises in inflammatory markers. (129) It has also shown anti-viral activity in vitro to many other viruses by preventing viral entry and replication. Examples include Coxsackievirus B, Cytomegalovirus, Enterovirus, respiratory syncytial virus Hepatitis C, Zika viruses, to name a few. (7)(28)(59)(111)(122)(139)

5. Echinacea

Echinacea (Echinacea purpurea) is a medicinal herb widely used for its immune-boosting properties. For common cold prevention, the use of a liquid extract, 0.9 ml three times per day (equivalent to 2400 mg of extract) for a minimum of four months has been used, while in the acute phase of cold development, up to 4.5 ml (4000 mg) has been used. (60) Meta-analysis shows that echinacea use may reduce the risk of common cold development by 10-58%, and days with cold by approximately a day and a half.

(63)(109) Echinacea may reduce the incidence of cumulative viral infections by 26% and recurring infections by 59%, including the influenza virus and parainfluenza virus. (60) Its immune-boosting effects may be related to associated increases in immune cell counts including white blood cells, monocytes, neutrophils, and natural killer cells, which fight infection. Furthermore, it may increase the suppression of free radical production in the later-phase of the cold by neutrophils. (41) Free radicals such as superoxide may have a role in the pathogenesis of viral infections. (4)

6. Oregano

The herb, oregano (Origanum vulgare) is commonly used in the food, cosmetics, and pharmaceutical industries. The essential oils are now also used for their anti-microbial, anti-viral, and anti-fungal properties. (76)

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Oregano essential oils are used for their anti-microbial, anti-viral, and anti-fungal properties.

Studies have assessed the anti-viral activity against certain viruses, including the murine norovirus, respiratory syncytial virus (RSV), Coxsackie virus B3 (CVB3), and herpes simplex virus type 1 in vitro. (40)(136)

7. Zinc

Zinc is also often recommended for its protective effect against the common cold. Zinc improves the anti-inflammatory and anti-oxidant profile by reducing in plasma interleukin-1 receptor antagonist, intercellular adhesion molecule-1, TNF-?, malondialdehyde (MDA), 4-hydroxyalkenals (HAE), and 8-hydroxydeoxyguanine (8-oHdG), and increases in IL-2 mRNA in mononuclear cells. (102)(103) The symptoms of viral infections, including those of the common cold, are considered to be consequences of the increased presence of pro-inflammatory cytokines such as TNF-? and many interleukins in response to viral invasion. (69) MDA, HAE and 8-oHdG are examples of biomarkers that lead to the production of free radicals, (38) which, as previously described, may have roles in the pathogenesis of viral infections. (4)

Several systematic reviews and meta-analyses show that 75 to 100 mg of elemental zinc as zinc acetate or zinc gluconate lozenges, once per day, within 24 hours of the onset of common cold symptoms, minimum 1 to 2 weeks to reduce the duration and symptoms of colds, in adults and children. (49)(50)(52)(53)(61)(113)

8. Probiotics

Though probiotics have been most widely used for their beneficial effects in the GI tract, research now shows that a healthy composition of bacteria in the GI tract can translate to improved immune function. This can also lead to improved regulation of anti-inflammatory and pro-inflammatory cytokines, and anti-oxidative biomarkers. (6)(85)(108)(134)

The benefits of probiotics can extend beyond their anti-microbial effects to also provide support against viral infections. For example, research is showing the potential benefit of probiotics as an adjunct therapy for in the regulation of white blood CD4 cell counts in patients with human immunodeficiency virus (HIV). (12)(26)(64)(86)(123)

Meta-analyses show that probiotics may reduce cold severity and have minor effects on cold prevention, as well as improve influenza vaccination efficacy for A/H1N1, A/H3N2, and B strains, but is dependent on strain and population. (62)(74)(131) Meta-analyses also show the efficacy of probiotics in reducing rates of respiratory tract infections in adults and children. (31)(46)(68)(95)(121)

In children, the use of 5 billion CFU of Lactobacillus acidophilus NCFM (ATCC 700396), twice per day, for a minimum of six months has been shown to reduce the incidence and severity of cold symptoms, while 10 billion CFU of Bifidobacterium animalis subs. lactis Bi-07 (ATCC PTA-4802) and Lactobacillus acidophilus NCFM (ATCC 700396), had similar effects for influenza. (75)

In adults, the use of 1 billion CFU of Lactobacillus paracasei 8700:2 (DSM 13434) and Lactobacillus plantarum HEAL 9 (DSM 15312), once per day for three months can reduce the incidence of colds and symptoms. (9) For influenza, 10 billion CFU of Lactobacillus fermentum CECT5716, once per day for two weeks before influenza vaccination and two weeks after, or Lactobacillus rhamnosus GG, twice per day for four weeks after influenza vaccination may reduce the future incidence of influenza compared with vaccination alone by increasing seroprotection (the extent of increased antibodies in response to infection), as well as natural killer cells, the T-helper response, and immunoglobulin A levels. (30)(94) The use of another probiotic, Saccharomyces cerevisiae (EpiCor®) at a dose of 500 mg per day for 12 weeks may reduce the incidence of cold/flu symptoms with or without prior vaccination and the duration of symptoms with prior vaccination. (88)(89)

9. Astragalus

The roots of Astragalus membranaceus have been used therapeutically for thousands of years in Traditional Chinese Medicine for its bioactive polysaccharides. As demonstrated in various studies, these polysaccharides possess widespread immunomodulatory, anti-inflammatory, anti-viral, anti-oxidant, and cardioprotective activities. (140)

In humans, Astragalus membranaceus formulations as injection or granules have been used as supportive therapy for myocarditis induced by viral infections. (45)(79) Oral liquid administrations have been shown to enhance cellular immunity in viral myocarditis patients. Specifically, OKT3, OKT4 cells and the OKT4/OKT8 ratio increase. (58) The use of 7.5 ml twice per day (equivalent to 1.23g of dry herb) for one week has also been shown to stimulate CD69 expression on white blood CD4 and CD8 T cells within 24 hours, which is maintained during the week of ingestion. (10) In comparison, stimulation of CD25 expression was greatest in the first day but not maintained over the rest of the week. (141)

Astragalus treatment can boost ?-interferon (?-IFN) and γ-interferon (γ-IFN), cytokines which play roles in viral replication. (130) Its anti-viral properties have also been demonstrated in patients with chronic viral hepatitis B by promoting recovery from viral infection and by preventing viral replication (83)(115). Astragalus extracts can also reduce the level of anti-inflammatory IL-4 and IL-10 cytokines, while increasing pro-inflammatory IL-2 and immune response-inducing γ-IFN in patients with viral herpes simplex keratitis. IL-4 and IL-10 may be typically reduced, while IL-2 and γ-IFN may be typically higher in these patients. (82)

Astragalus membranaceus has also been shown to possess anti-influenza virus properties by modulating the expression of toll-like receptors (TLR) TLR3, transforming growth factor-β (TGF-β)-activated kinase 1 (TAK1), TRAF-family member associated NF-κB-activator (TANK) binding kinase 1 (TBK1), interferon regulatory factor 3 (IRF3), and interferon-β (IFN-β) in the TLR3-mediated signaling pathway in vitro. (77) TLR-mediated pathways are involved in the activation of various inflammatory responses with exposure to pathogens. (96) Furthermore, it provided anti-oxidative effects by increasing superoxide dismutase and reducing MDA. (77)

10. Mushrooms

Similarly to astragalus, mushrooms and their active components have been extensively used in Traditional Chinese Medicine for their immune-stimulating, anti-microbial, anti-fungal, anti-tumor, and anti-viral properties. (138)

Several in vitro studies have shown broad anti-viral effects, including anti-viral effects against influenza, using a variety of mushroom extracts including Ganoderma lucidum, Lentinus edodes, Grifola frondosa, Agaricus brasiliensis, (5)(35) Phellinus igniarius, (72) and Rozites caperata. (100) The following provides evidence for the use of medicinal mushrooms and their bioactive ingredients in viral infections from human trials.

Bioactive ingredients



The ingestion of lentinan, a major active substance in Lentinus edodes mushrooms at doses of 2.5 mg per day for six weeks also increased the number of circulating B lymphocytes in healthy elderly adults. (37) As an adjunct anti-viral therapy in patients with HIV, 2 mg (i.v.) of lentinan increased the CD4 cells for up to 38 weeks compared with anti-retroviral therapy alone. (43)

Another extract from Basidiomycetes mushrooms called the 'active hexose correlated compound' has been used to improve the immune status of healthy individuals after receiving the influenza B vaccination. Ingesting 3 grams per day for three weeks post-vaccination increased the number of natural killer cells and CD8 T cells, and improved antibody titers to influenza B compared with vaccine alone. (107)

Agaricus blazei Murill (Cogumelo do Sol or Himematsutake)

The daily use of 1.5 grams of Agaricus blazei Murill has been safely used over one year to reduce aspartate and alanine aminotransferases in patients with hepatitis B. This may provide indication that Agaricus blazei Murill may assist in the normalization of liver function following its infection by the hepatitis virus. (54)

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Intake of shiitake mushrooms has been shown to stimulate the immune response.

Lentinula edodes (Shiitake)

In healthy adults, the use of 5 to 10 grams of Shiitake mushrooms over four weeks has been shown to stimulate γδ-T cells, natural killer T cells, and secretory IgA, involved in the immune response. Consumption may alter the inflammatory profile as shown by reduced C-reactive protein (CRP), and macrophage inflammatory protein-1α/chemokine C-C ligand 3 (MIP-1α/CCL3) levels, and increased IL-4, IL-10, TNF-α, and IL-1α levels. (29)

Multi-mushroom products

Another medicinal mushroom product called Immune Assist 25/7™ containing compounds Lentinus edodes, Trametes versicolor, Ganoderma lucidum, Agaricus brasiliensis, Cordyceps sinensis, and Grifola frondosa at a dose of 2.4 g for two months increased CD4+ T-lymphocyte numbers in HIV patients. (1) The combination of Trametes versicolor and Ganoderma lucidum has been shown to clear oral human papillomavirus 16 and 18 after two months of treatment. (32)

11. L-lysine

The essential amino acid L-lysine has been used in a wide variety of applications. In relation to anti-viral therapy, L-lysine has been most studied for its uses in herpes simplex virus infections. (114) Many trials have used doses ranging between 300-3000 mg per day for up to one year for herpes prophylaxis and symptom treatment. (44)(84)(87)(112)(117) However, systematic reviews indicate that treatment with more than 1 gram may be required for prophylaxis or treatment of the herpes viruses, while doses greater than 3 grams per day can improve patient's self-assessed improvements. (81)

A trial supplying 1000 mg of lysine per day for 16 weeks to a population where bacterial and viral causes of diarrhea commonly occur also showed a reduction in diarrhea episodes and days of sickness in children, while reducing the number of days with sickness and number of episodes of coryza in men. In women, serum ferritin and CRP levels decreased with lysine supplementation. (39) These biomarkers may be increased in the presence of influenza infections. (36)

12. Vitamin D

Vitamin D has been shown to be involved in modulation of the immune system due to its ability to bind to vitamin D receptors expressed throughout the body's nucleated cells, including antigen-presenting cells within the innate and adaptive immune systems. (21) Vitamin D insufficiencies or deficiencies have been linked to a variety of viral infections, including chronic hepatitis B, (55) hepatitis C virus, (120) or other viral infections leading to upper respiratory tract infections or pneumonia. (2)(101)

Vitamin D may also be used in the prevention and/or treatment of URTI in adults and children. One meta-analysis showed that doses ranging from 400 to 2000 IU per day over three months to three years reduced the incidence and number of events of respiratory tract infections in children and adults. (22) A four-month protocol of 400 IU of daily vitamin D also reduced the duration and severity of URTIs in adults. (110) In children aged one to five, daily administration of 400 IU for four months was equally as effective as 2000 IU in reducing the risk for wintertime URTIs, (2) though doses of 1200 IU for approximately four months in the winter can reduce the incidence of Influenza A in children aged six to 15, (119) and in infants of less than one year of age. (137) In older Vietnamese children aged three to 17, weekly ingestion of 14000 IU over eight months reduced the incidence of non-influenza respiratory virus infections, but not influenza infections. (80)

Vitamin D administration as an adjunct to other anti-viral therapies may have synergistic benefits in infections such as chronic hepatitis C (66) and HIV, (34) and may reduce inflammatory markers, such as TNF-α and IL-6, after influenza vaccination, while promoting transforming growth factor-beta (TGF-β), a multifunctional cytokine involved in cell growth, proliferation, and programmed cellular death. (42)

The bottom line COVID-19 has rapidly spread on a global scale, particularly affecting older adults and individuals with underlying immune dysfunction, resulting in manifestations that mimic the common cold or flu. Though there is no current cure for the infection and the content of this article is not specific to SARS-CoV-2, there are several best practices that can be used to support immune function, including several immune-boosting foods and supplements that may be used for their anti-viral properties.

For regular updates on COVID-19's global status, please refer to the CDC's and the WHO's websites for more information.

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