Herbal Strategies Used in Chinese Hospitals During Epidemics

Classical Chinese herbal formulas have had thousands of years of history in use during epidemics.

Note: This blog post was inspired by an oral presentation given by Dr. John Chen, PhD, PharmD, OMD, L.ac.

The SARS-Coronavirus 2 crisis has had devastating effects all over our world, with some parts of the world being especially hard hit as compared to others. Likewise the medical approaches in hospitals have varied greatly across nations. It is interesting to note that in China, and particularly in the hard hit regions within Hubei province, 85% of hospital cases have utilized Chinese herbal treatments alongside traditional western medicine. With other considerations such as the use of PPE, strict quarantine efforts by government and social distancing, could this be one reason why death rates in the nation have been moderate as compared to others?

Chinese herbs have nearly 2,000 years of traditional use, with a wide range of research showing immune supportive, immune regulatory and anti-viral effects of the plant compounds. A history of viral epidemics that have ranged from SARS Coronavirus 1 in 2003, H1N1 and MERS have allowed for larger sized case studies and randomized trials to additionally be published.

What are some of the individual herbs in Chinese medicine that are key players during viral epidemics? Here are just a few:

Immune Supportive and Immune Regulatory Herbs:

• Astragalus (Huang Qi 黄芪)：Immune protective and immune modulatory. Associated with promotion of T cell lymphocytes and natural killer cells. Polysaccharides from the root have been shown to activate B cell lymphocytes, which are responsible for the secretion of antibodies (9, 10).

• Panax Ginseng (Ren Shen 人参)：Immune protective and modulatory. It additionally has been shown to reduce production of pro inflammatory cytokines (IL-6 and TNF-alpha) in viral upper respiratory infections, such as H1N1 and Avian Flu (3).

• Siberian Ginseng (Ci Jia Wu 此家务)：Has shown a pronounced effect on T lymphocytes, predominantly of the helper/inducer type, but also on cytotoxic and natural killer cells. In addition, a general enhancement of the activation state of T lymphocytes has been observed (1).

• Licorice (Gan Cao 甘草): Contains triterpenes and flavonoids that activate T cell proliferation, are antiviral and anti-inflammatory. Additionally, Glycyrrhizin, an active constituent of the root, has been shown to inhibit SARS Coronavirus 2 virus in vitro (11).

Individual Herbs with Anti-Viral Actions:

• Isatis tinctoria (Ban Lan Gen 板蓝根): Antiviral effect against influenza A, human or avian influenza virus, adenovirus, swine originating virus and coxsackie virus B3. It has been shown to directly inhibit enzyme activity and replication of SARS Coronavirus (5, 7).

• Honeysuckle (Jin Yin Hua 金银花): Exhibits a broad spectrum of inhibitory actions against a variety of bacteria and viruses. Shuangkangsu, a cyclic peroxide from the plant, has shown antiviral activities against both influenza and respiratory syncytial viruses. Jin Yin Hua has been shown to inhibit replication of SARS Coronavirus 2 in vitro (5, 7).

• Fructus forsythiae (Lian Qiao 连翘): Antiviral and found to be inhibitory towards SARS Coronavirus 2 in vitro (5, 7).

• Leaf of Isatis (Da Qing Ye 大青叶): Mediates 3C like protease, which is responsible for processing of replicase polypeptides. In other words, the extract helps prevent cleavage of an important enzyme that normally facilitates the replication process of SARS Co-V virus (6).

• Leaf of Chinese Toona (Xiang Chun Ye 香椿叶): Contains a compound (TSL-1) that selectively binds to SARS-CoV virus and inhibits the entry of the virus into the host cells (2).

• Chinese Sumac (Wu Bei Zi 五倍子): Contains tetra-O-galloyl-B-D-glucose (TCG) and luteolin, which have been shown to bind to the surface spike protein of SARS Co-V virus and interfere with entry of the virus into its host cells (13).

Additionally, specific herbal formulas have been utilized during all stages of viral epidemics, both during the SARS Coronavirus crisis of 2003 and in the most recent SARS Coronavirus 2 crisis. The formulas were found to be most effective during the preventative and early symptomatic stages and used alongside intensive medical care in later stages.

Herbal Formulas and SARS Coronavirus

The following two formulas are being studied for prevention and treatment of SARS Coronavirus 2. It is important to note that in traditional Chinese medicine, formula choice will vary based on the signs, symptoms and level of disease progression in an individual patient, often challenging the “one size fits all” western approach to clinical trials. Modified versions of Xiao Chai Hu Tang, Yin Qiao San and Sang Ju Yin are other examples of formulas that have been utilized for SARS Coronavirus 2 in Chinese hospitals.

Preventative Formula: Yu Ping Feng San (玉屏风散). A traditional formula that consists of Astragalus, Bai Zhu, Fang Feng, and Licorice. A Hong Kong study of 16,437 hospital care workers revealed a 0% infection rate in the herb group as compared to a 0.4% infection rate in the non herb group. This is likely due to the modulatory effects on the T cell lymphocyte CD4 to CD8 ratios in individuals taking the formula (4, 8).

Antiviral Formula: Qing Fei Pai Du Tang (清肺排毒汤). According to a report by the National Administration of Traditional Chinese Medicine, up to February 5th, 2020, 214 COVID-19 patients were treated with Qing Fei Pai Du Tang in Shanxi, Hebei, Heilongjiang and Shaanxi Provinces with overall effective rate ≥ 90%. After that, 701 COVID-19 patients were treated with Qing Fei Pai Du Tang in 10 provinces in China. The result showed 130 patients (18.5%) with complete recovery, improvement in 268 patients (38.2%), and stabilization in 212 patients (30.2%) (12).

Resources:

1. Bohn, B., Nebe, C. T., & Birr, C. (1987). Flow-cytometric studies with eleutherococcus senticosus extract as an immunomodulatory agent. Arzneimittel-Forschung, 37(10), 1193-1196.

2. Chen, C. J., Michaelis, M., Hsu, H. K., Tsai, C. C., Yang, K. D., Wu, Y. C., ... & Doerr, H. W. (2008). Toona sinensis Roem tender leaf extract inhibits SARS coronavirus replication. Journal of ethnopharmacology, 120(1), 108-111.

3. Kang, S., & Min, H. (2012). Ginseng, the'immunity boost': the effects of Panax ginseng on immune system. Journal of ginseng research, 36(4), 354.

4. Lau, J. T., Leung, P. C., Wong, E. L. Y., Fong, C., Cheng, K. F., Zhang, S. C., ... & Ko, W. M. (2005). The use of an herbal formula by hospital care workers during the severe acute respiratory syndrome epidemic in Hong Kong to prevent severe acute respiratory syndrome transmission, relieve influenza-related symptoms, and improve quality of life: a prospective cohort study. Journal of Alternative & Complementary Medicine, 11(1), 49-55.

5. Li, Y., Ooi, L. S., Wang, H., But, P. P., & Ooi, V. E. (2004). Antiviral activities of medicinal herbs traditionally used in southern mainland China. Phytotherapy Research: An International Journal Devoted to Pharmacological and Toxicological Evaluation of Natural Product Derivatives, 18(9), 718-722.

6. Lin, C. W., Tsai, F. J., Tsai, C. H., Lai, C. C., Wan, L., Ho, T. Y., ... & Chao, P. D. L. (2005). Anti-SARS coronavirus 3C-like protease effects of Isatis indigotica root and plant-derived phenolic compounds. Antiviral research, 68(1), 36-42.

7. Luo, H., Tang, Q. L., Shang, Y. X., Liang, S. B., Yang, M., Robinson, N., & Liu, J. P. (2020). Can Chinese medicine be used for prevention of corona virus disease 2019 (COVID-19)? A review of historical classics, research evidence and current prevention programs. Chinese journal of integrative medicine, 1-8.

8. Poon, P. M. K., Wong, C. K., Fung, K. P., Fong, C. Y. S., Wong, E. L. Y., Lau, J. T. F., ... & Au, S. W. N. (2006). Immunomodulatory effects of a traditional Chinese medicine with potential antiviral activity: a self-control study. The American Journal of Chinese Medicine, 34(01), 13-21.

9. Qu LL, et al. Astragalus membranaceus injection delayed allograft survival related with CD4+ CD25+ regulatory T cells. Transplant Proc. 2010 Nov;42(9):3793-7.

10. Shao, B. M., Xu, W., Dai, H., Tu, P., Li, Z., & Gao, X. M. (2004). A study on the immune receptors for polysaccharides from the roots of Astragalus membranaceus, a Chinese medicinal herb. Biochemical and biophysical research communications, 320(4), 1103-1111.

11. Wang, L., Yang, R., Yuan, B., Liu, Y., & Liu, C. (2015). The antiviral and antimicrobial activities of licorice, a widely-used Chinese herb. Acta Pharmaceutica Sinica B, 5(4), 310-315.

12. Yang, Y., Islam, M. S., Wang, J., Li, Y., & Chen, X. (2020). Traditional Chinese medicine in the treatment of patients infected with 2019-new coronavirus (SARS-CoV-2): a review and perspective. International journal of biological sciences, 16(10), 1708.

13. Yi, L., Li, Z., Yuan, K., Qu, X., Chen, J., Wang, G., ... & Chen, L. (2004). Small molecules blocking the entry of severe acute respiratory syndrome coronavirus into host cells. Journal of virology, 78(20), 11334-11339.