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Avian Flu and Other Epidemics

alert by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon, March 2006

There are growing concerns about a possible pandemic of virulent influenza, possibly from mutations of a "bird flu" (or, avian flu) that has now occurred across much of Asia and Europe. Thus far, the avian flu has been transmitted primarily from bird to bird or from bird to human, and the number of human cases has been small, because it is necessary to have some direct contact with infected birds (those infected mainly involve people who raise chickens, ducks, or geese). However, it has been found that this virus can infect other animals (e.g., pigs, ferrets), and recent reports indicate that common pets, such as cats, are also at risk.

Currently, when this flu virus infects humans, there is a greater than 50% death rate associated with it, which is one of the reasons for the expressed fears about it. The primary concern is that a mutation will arise that allows human to human transmission; in other words, that the flu could be a sneeze away. Already, researchers have noted some genetic variations in viral samples indicating changes towards capability to transmit among humans. If the mutation occurs that permits relatively easy human-to-human infection, the virus may be less lethal than it is now, but would still be a formidable agent of disease. Recent analysis has shown that the bird virus is genetically similar to the "Spanish flu" that caused the deaths of about 50 million people worldwide in 1918-1919 (when the world population was less than one-third what it is now). Those deaths included people who were relatively healthy; the death rate from the Spanish flu was only about 5%.

There is a possibility that a human epidemic of this virus will come in the next flu season (2006-2007). Extensive efforts are being used to control this flu; for example, by destroying chicken populations that are infected, as well as eliminating potentially contaminated fowl and wild animals in the immediate vicinity. This approach has had some success, but the growing number of bird farms infected over a widening geographic area is worrisome.

With the benefits of modern genetics and pharmaceutical science, a vaccine may soon be developed; vaccines were not part of the technology available in 1918 for the Spanish flu, nor in the other two large epidemics of 1957-1958 and 1968-1969. Looking back at the public reaction to the flu vaccine shortage in America that occurred in the 2004-2005 season, there are great concerns about the supplies of flu vaccine that would have to be developed. Substantial efforts are underway to enhance production capabilities.

An analysis presented in 2005 indicated that flu vaccines may have a lower efficacy rate than had been previously assumed, as low as 30% (which is still sufficient to justify their use in people who are at risk of death or severe debility from the flu). There are also flu drugs now coming into broader use, such as the inhalant Relenza (zanamivir), which was approved by the FDA in 1999, and the pill/syrup version called Tamiflu. Several countries are stockpiling supplies. The efficacy of these drugs is also limited, but the initial claims (which may be adjusted as more people use the drugs under varying circumstances) indicate a good response: interrupting flu development when used early enough in 80% of cases; reducing symptom severity by about 40%; and reducing duration of the flu symptoms by about 30%.

The avian flu is only one of the possible scenarios for a serious flu epidemic. Other flu viruses might be able to spread more extensively than before. A 2004 U.S. planning document, not based on the avian flu, depicted a scenario where 89 million Americans became sick with influenza, flooding hospitals and overwhelming the medical system, with as many as 207,000 deaths. During ordinary influenza years, the disease is thought to kill at least 20,000 in the U.S. (some estimates double that number), mostly elderly persons with other existing health problems, particularly those who are immobilized by stroke or heart attack; those who have serious respiratory ailments such as pneumonia, chronic obstructive pulmonary disease, asthma, and emphysema; and those with compromised immunity (such as those undergoing therapies that have immunosuppressive effects, as with some cancer drugs and anti-arthritis treatments).

In the 2003-2004 season, the flu strain that affected the U.S. was particularly virulent. It caused an unusually high number of fatalities in children (a total of 152 childhood deaths due to influenza for the 2003-2004 season). The influenza season usually peaks in November-February, with some early cases appearing in October and some lingering spread of the disease in March (in 2003, the peak occurred during the week of December 13-20), but the 2004-2005 season started slowly and the peak did not occur until February. Outside of these months, there are relatively few cases of influenza, but there are other diseases that present symptoms similar to influenza and may not be distinguished from it without medical testing. A common intestinal infection, the Norwalk virus (and related Noroviruses) produces what is sometimes called "intestinal flu."

Toward the end of the 2004-2005 flu season, a California strain arose that appeared to cause very severe symptoms (the vaccine for the 2005-2006 flu season included protection from that virus, as well as from two other strains, one from New Caledonia and one from Shanghai). Vaccine supplies appear to be adequate for all those in high risk groups as well as others who are in circumstances where becoming infected is likely (health care workers, school teachers, etc.), so long as the spread of the disease follows the typical patterns.


Unlike the vaccines, which are made in response to flu strains as they appear, Chinese herb therapies for influenza are not specific for the viral strain. Instead, they may provide general actions, such as to help boost the immune response so that it is able to eliminate the virus faster. At high enough dosage the herbs may have some direct inhibitory effects on viral reproduction; they may also ameliorate some of the symptoms, thus making a serious infection seem mild.

Instead of having a single herb or a single formulation as the response to flu, there are a collection of herbs and formulas that have developed a good reputation. During the period from the 1950s to the 1970s, several large scale studies were undertaken in China to evaluate the use of traditional herb formulas and newer herbal remedies to prevent and treat influenza, with favorable results reported for several compounds. These findings appeared in medical journals and in books summarizing progress in Chinese herb research. The information has been gathered at ITM, while many of those original publications are no longer available due to limited print runs. While there is insufficient proof from these studies that Chinese herbal therapies can cure or impede influenza because of problems in methodology and reporting, practitioners of Chinese medicine and their patients are convinced of the efficacy of this approach.

Routine prescription of Chinese herbs for influenza or other therapeutic applications remains limited primarily to the countries where herbal medicine is officially recognized, such as China, Japan, and Korea. In other countries, the herbs have been made available mainly through the work of licensed acupuncturists, naturopaths, and other non-M.D. practitioners, as well as through direct marketing of products to consumers.

The non-toxic herbs found useful in these studies have been incorporated into formulations that ITM has produced for practitioners to use. Several of the formulations, such as Ilex 15, have been available for more than 15 years, so that there is some experience gained through several influenza seasons.

Practitioners of Chinese medicine in the U.S., Canada, and Europe will be called upon to provide natural therapies for influenza this year as before, with a potential for higher demand and with more concern about prevention strategies. Even though such therapies are not proven to be effective, many people will feel the need to do everything that seems reasonably possible. Thus, it is worthwhile to review the therapeutic approach described by the Chinese and to offer some of the readily available remedies (ITM formulary items will be described here; others are easily obtained).


Chinese herb therapy, applied to address the first signs of influenza, might prevent the infection from developing into the full symptomatic disease. For persons who are highly susceptible to influenza and those who tend to experience severe symptoms, as well as during influenza seasons that are defined as being highly virulent or dangerous, it may be prudent to treat even the initial symptoms as though a severe disease was about to develop. These herbal remedies would be used in persons who are developing symptoms despite having been vaccinated (since there is the possibility of vaccine failure, especially later in the season when new strains might dominate) and could also be used along with drugs such as Tamiflu, which are not completely efficacious on their own.

To review key herbs that are used in these treatments, please see these articles:

Forsythia and Lonicera (antiviral herbs)

Shuanghuanglian (this article focuses on three antiviral herbs; the two herbs in the article above, plus scute)

Schizonepeta and Mentha (these herbs are used to alleviate symptoms)

Yin Qiao San (this article describes a common anti-influenza formula used in China; it includes forsythia, lonicera, schizonepeta, and mentha).

The Jade Screen (article about a formula for preventing infections and aiding recovery afterward)

A protocol using ITM formulations (which are prescribed by health professionals and are not sold in stores) could be designed in this manner (these dosages are for adults):

Ilex 15 (Seven Forests) is a complex formulation of Chinese herbs that are used to treat upper respiratory system infections. The pattern of herb combining follows principles used in producing two popular patent remedies from China: Yin Qiao Jie Du Pian and Gan Mao Ling. This formula has been used for 15 years. It is suitable for use by itself in the early stage of common influenza and other upper respiratory viral infections. ITM also provides a modification of the original Yin Qiao Jie Du Pian (Pine Mountain), which has been modified with herbs indicated as effective for influenza by ongoing research in China. In addition, there is a potent broad-spectrum antiviral combination called Isatis 6 that may be used alternatively or along with Ilex 15.

Myrolea-B (White Tiger) is a simple formulation of highly concentrated extracts from four Chinese herbs and one Western herb. The Chinese herbs include forsythia and lonicera, two of the key ingredients of Ilex 15 (and the main antiviral ingredients of Yin Qiao Jie Du Pian), thus boosting the dosage of these essential ingredients. Myrolea-B also contains the antiviral agents scute (huangqin) and terminalia (hezi). The Western herb in this formulation is olive leaf, which is one of the primary anti-viral herbs derived from the European tradition.

Calmagnium (White Tiger) is a comprehensive mineral and vitamin supplement (not a Chinese formula). The concept behind its use is that by providing optimal or even high levels of certain nutrients, the immune system has a stronger effect against pathogens. For example, it is considered possible that vitamin C, zinc, and selenium contribute to antiviral activity. The point of providing a broad nutritional supplementation, rather than just focusing on a few of the established ingredients, is to assure a more balanced effect. In China and Japan, it is increasingly common to prescribe nutritional supplements, similar to this, along with herb remedies.

Quercenol (White Tiger) is an antioxidant mixture. It has recently been reported that influenza causes oxidative stress that adversely affects the lungs, perhaps increasing symptoms and susceptibility to secondary lung infections. There is a decline in vitamin E levels. Quercetin, the main ingredient in Quercenol, has been shown to increase pulmonary concentrations of the antioxidants catalase, reduced glutathione, and superoxide dismutase. By taking Quercenol, the vitamin C intake from Calmagnium is increased (total of 1162 mg per day with the above suggested dosing) as is the vitamin E intake (total of 337 IU per day with above dosing). In addition, zinc supplementation is often recommended for to boost immune responses; the use of Quercenol with Calmagnium at the suggested dosing provides 25 mg of zinc. Selenium from Calmagnium alone at the dose of 1 tablet three times daily is 75 mcg, but adding Quercenol brings it to 175 mcg.

The antiviral agents are expected to have their best effect at the earliest sign of infection and for the phase of the disease where the amount of virus is exponentially growing, perhaps the first two to three days of symptoms. After that, the virus comes under some degree of control, even though symptoms can persist. However, additional symptoms can be generated if a bacterial infection arises; typically, a bronchial infection develops, and it may persist for several days or weeks if not successfully treated (if herbal therapy is not successful, antibiotics should be used in cases of bacterial infections). After the initial viral development phase, one may focus more on symptomatic relief, for example, deleting Ilex 15 in the regimen above and replacing it with another formula; aimed at relief of symptoms, such as for nasal congestion, sore throat, or bronchial infection with cough. Examples of those therapies include these Seven Forests formulas:

Belamcanda 15: suited for respiratory bacterial infection that accompanies or follows influenza

Chyrsanthemum 9: for headache, fever, sinus congestion accompanying influenza

Gardenia 7: for sore throat

Lily 14: for dry, irritated throat and dry cough


For those who are concerned about high susceptibility to influenza (due to past experience of frequent infection by viruses or a high level of exposure to crowds), immune enhancing formulas, such as Jade Screen Tablets or Astragalus 10+, may be taken during the flu season (e.g., for up to about 16 weeks) in an effort to avoid developing a symptomatic infection after exposure. Jade Screen Formula (with astragalus as a major constituent) and its variants are the most widely studied prescriptions for prevention of upper respiratory tract infections. ITM's version of the formula includes additional herbs benefiting the lungs: the anti-infection herb houttuynia, the yin nourishing glehnia, and the congestion-alleviating centipeda (an herb, not to be confused with the insect centipede). Astragalus 10+ is especially suitable for persons of middle age or older, as it also contains tonics for the kidney/liver as part of the therapeutic approach to immune enhancement. Greater immune enhancing effects may be attained by including, along with one of these tonifying formulas, a high dose of either astragalus (using Astragalus Extract Tablets) or cordyceps (using Cordyceps Tablets); these herbs also strengthen the lungs. ITM has received reports that some patients successfully use Ilex 15 as a preventive; this formula may function in this role by helping inhibit the virus as soon as exposure occurs, perhaps being effective at dosages lower than those described for treatment of the disease once symptoms appear.

It is important to note that high doses of the tonic formulas with astragalus may not be effective when the infection begins producing symptoms. The flu symptoms include the adverse impact of a high immune response, and attempts to elevate that immune response will not only fail to have a substantial extra impact on the virus but may contribute to the severity of the symptoms. Thus, one should be careful about attempting to apply this approach. Generally, the immune based therapies are applied either during a preventive health care phase of treatment or during a recovery phase when the dominant symptoms are reducing rather than at the time when the symptoms of an infection are first noted.

Some of the suggested ITM formulations are relatively new, including Myrolea-B, Yin Qiao Jie Du Pian, Chrysanthemum 9, Astragalus Extract Tablets, Cordyceps Tablets, and Gardenia 7. All of these, and the other formulations mentioned here, are included in the book A Bag of Pearls (2004). Additional suggestions for treatment of influenza or its symptoms may be gleaned from the pages describing the formulas and in the index of formula indications.

PLEASE NOTE: The side-by-side presentation of the following formulas
is not intended to suggest any particular pairings, it is for presentation only.

Standard Anti-Influenza Formulations
Ilex 15
maodongqing Ilex 14%
jinyinhua Lonicera 9%
lianqiao Forsythia 7%
banlangen Isatis root 7%
bohe Mentha.. 7%
juhua Chrysanthemum 7%
zhushagen Ardisia root 7%
jiegeng Platycodon 7%
lugen Phragmites 6%
jingjie Schizonepeta 6%
fangfeng Siler 5%
qianghuo Chiang-huo 5%
ganjiang Ginger 5%
wuzhuyu Evodia 4%
gancao Licorice 4%
Yin Qiao Jie Du Pian
jinyinhua Lonicera 12%
lianqiao Forsythia 12%
niubangzi Arctium 12%
banlangen Isatis root 10%
chuanxinlian Andrographis (e) 10%
jiegeng Platycodon 10%
dandouchi Soja 10%
danzhuye Lophatherum 8%
bohe* Mentha 8%
jingjie Schizonepeta (e) 8%
* a high menthol content extract is used

Supplemental Influenza Formulations:
may be added to the above or used instead
jinyinhua Lonicera 25%
lianqiao Forsythia 25%
  Olive leaf 25%
huangqin Scute 20%
hezi Terminalia 10%
Isatis 6
daqingye Isatis 25%
huzhang Hu-chang 15%
xiakucao Prunella 15%
baihuasheshecao Oldenlandia 15%
chuanxinlian Andrographis 15%
jinyinhua Lonicera 15%

Nutritional and Antioxidant Therapy:
key elements are quercetin, vitamins C and E, and zinc.


Four tablets provide:
(percentage of U.S. RDA in parentheses)
(55) Calcium 550 mg
(100) Magnesium 400 mg
(67) Zinc 10 mg
(100) Manganese 2 mg
(75) Copper 1.5 mg
  Boron 1 mg
(167) Chromium 200 mcg
(143) Selenium 100 mcg
(67) Molybdenum 50 mcg
(100) Vitamin A 5,000 IU
  β-carotene 10,000 IU
(1333) Vitamin B1 20 mg
(1176) Vitamin B2 20 mg
(210) Vitamin B3 40 mg
(400) Vitamin B5 40 mg
(2000) Vitamin B6 40 mg
(3333) Vitamin B12 200 mcg
(200) Folic acid 800 mcg
(333) Biotin 1 mg
(833) Vitamin C 500 mg
(75) Vitamin D3 300 IU
(167) Vitamin E 50 IU
(125) Vitamin K1 100 mcg
Two tablets provide:
percentage of U.S. RDA in parentheses
  Quercetin 400 mg
  Silybum marianum (e) 250 mg
  Proanthocyanadins 125 mg
  Green tea polyphenols 150 mg
  Mixed carotenoids 30 mg
(1000) Vitamin E 300 IU
(830) Vitamin C 500 mg
(67) Zinc 10 mg
(143) Selenium 100 mcg

Formulas for Prevention via Immune Enhancement;
also for recovery phase
Jade Screen Tablets
huangqi Astragalus 25%
fangfeng Siler 18%
baizhu Atractylodes 15%
ebushicao Centipeda 12%
yuxingcao Houttuynia (e) 12%
beishashen Glehnia 12%
gancao Licorice 6%
Astragalus 10+
huangqi Astragalus (e) 12%
ciwujia Eleuthero (e) 12%
lingzhi Ganoderma (e) 10%
maimendong Ophiopogon 10%
nüzhenzi Ligustrum 10%
heshouwu Ho-shou-wu 8%
roucongrong Cistanche 7%
baizhu Atractylodes 7%
gancao Licorice 6%
renshen Ginseng 6%
wuweizi Schizandra 6%
sangshen Morus fruit 6%

Immune Boosters; may be added to the formulas above
Astragalus Extract Tablets
huangqi Astragalus 75%
danshen Codonopsis 25%
Cordyceps Tablets
chongcao Cordyceps 34%
wujiashen Eleuthero 33%
hongjingtian Rhodiola 33%


Formulas for Secondary Effects:
Lung congestion and infection; headache and sinus congestion
Belamcanda 15
shegan Belamcanda 8%
yuxingcao Houttuynia 8%
shishangbo Selanginella 8%
lugen Phragmites 7%
xingren Apricot seed 7%
sangye Morus leaf 7%
zhuli Bamboo sap 7%
jiegeng Platycodon 7%
baibu Stemona 7%
maimendong Ophiopogon 6%
zhebeimu Fritillaria 6%
niubangzi Arctium 6%
baiqian Cynanchum 6%
ganjiang Ginger 5%
gancao Licorice 5%
Chrysanthemum 9
yejuhua Chrysanthemum 16%
manjingzi Vitex 12%
gegen Pueraria (e) 12%
chouwutong Clerodendron (e) 10%
sangye Morus leaf 10%
chuanxiong Cnidium 10%
niuxi Achyranthes 10%
tianma Gastrodia (m)* 10%
baijili Tribulus 10%
* gastrodia mushroom, Armillaria mellea, is used as a replacement for gastrodia

Formulas for Sore Throat and for Dry Throat and Dry Cough
Gardenia 7
zhizi Gardenia 30%
jiegeng Platycodon 15%
gancao Licorice 15%
hezi Terminallia 10%
bohe Mentha 10%
shengdi Rehmannia 10%
niubangzi Arctium 10%
Lily 14
baihe Lily 12%
muhudie Oroxylum 9%
maimendong Ophiopogon 9%
yuzhu Yu-chu 8%
dihuang Rehmannia 8%
mingdangshen Changium 7%
pangdahai Sterculia 6%
nanshashen Adenophora 6%
beishashen Glehnia 6%
xuanshen Scrophularia 6%
niubangzi Arctium 6%
jiegeng Platycodon 6%
zhebeimu Fritillaria 6%
gancao Licorice 5%


IMPORTANT REMINDER: There is no clinical evidence that the specific formulas mentioned above provide any protection from or effective treatment for influenza (or related disorders). The information about these formulas is given here to illustrate the types of ingredients that practitioners of Chinese herbalism (such practitioners are usually licensed acupuncturists) might give to their patients, including the dosage, the timing in relation to beginning of influenza symptoms, and the duration of use (a nutritional supplement comprised of vitamins and minerals is also mentioned). Such practitioners might recommend these specific formulas or many others that have a similar design. Several articles are referenced in the above description as a resource to learn more about certain of the ingredients and about related formulas described in the Chinese herbal literature