An overview of common respiratory pathologies

present at this time

A review of available evidence-based

ingredients and protocols

Concluding remarks, additional resources,

and questions

A review of basic immunology knowledge

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810961/figure/F1/?report=objectonlyhttps://www.ncbi.nlm.nih.gov/books/NBK8423/ (graphics not so good)

Braciale, T.J., et al. (2013). Immunity to viruses.

Optional caption with additional info

● Current Novel Coronavirus Disease 2019

● SARS-CoV-2 virus (87% match to SARS-CoV-1)

● First case reported December 31st, 2019 in Wuhan, China

As of March 18th, 2020:

● Worldwide: 159 countries, ~ 200,000 confirmed cases, ~ 8,000 deaths (~ 4.0%)

● USA: > 3,500 confirmed cases, > 60 deaths

● Canada: > 450 confirmed cases, > 5 deaths

Novel Characteristics:

● Uses ACE2 to enter cells (one of three known viruses to do this)

● Assumed to manipulate interferon levels like SARS-CoV-1

● Lipid-enveloped virus

Treatment Supportive Supportive + Vaccine Supportive + Vaccine Supportive Supportive + Vaccine

Vaccine available No (> 20 in development)

Yes Yes No Yes (but inconsistent)

# of confirmed cases

> 200,000 > 8,000 700M-1.4B ~ 2,500 ~ 5 million per year

# of confirmed deaths

> 8,000 774 151,000-575,000 866 ~ 650,000 per year

# of countries affected

159 29 Worldwide 27 Worldwide

Mortality 2%-5.0% (~ 3.4%) 10%-50% (over 60) 0.01-0.08% 34% 0.1-1.0%

Animal origin Bats Bats Pigs Bats n/a

Type of virus Coronavirus Coronavirus Influenza Coronavirus Influenza

Note: there are 4 types of influenza viruses (A-D), with a possible 198 subtypes (eg. H1N1) of Influenza A alone.Note: there are also 4 subtypes of coronavirus (alpha-delta), with seven that are identified to cause disease in humans.

● Natural hosts: bats and rodents

● Can be transmitted to other intermediary

mammals (e.g., civets and camels)

● Primarily transmitted between humans via

respiratory droplets

● Touching of eyes, nose, or mouth can lead to

transmission

● Aerosols or fomites may play a secondary role

in transmission

● Higher mortality rate than influenza (3.4%*)

● Primarily in the elderly over age 70 and/or

those with predisposing respiratory condition

● Low mortality rate (typical to the common flu)

in people under the age of 65

● No reported deaths in Children under the age

of 9

● Very mild or asymptomatic disease in most

World Health Organization (WHO). Novel Coronavirus (COVID-19) Situation. Our World in Data. Coronavirus Disease (COVID-19) – Statistics and Research.

● No vaccine or specific treatment currently

available for COVID-19

○ US and Chinese health authorities are

actively working on a vaccine

○ More than 20 vaccines in development

○ Potential preliminary trials in March,

projected release in April

○ Treatment is purely supportive

■ Hygiene, oxygen, etc

● Self-isolation

● Best hygiene practices

● Focus on the pillars of immune health

○ Diet

○ Exercise

○ Stress

○ Sleep

Centers for Disease Control and Prevention (CDC). (2019). Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19).

● SARS-CoV-2 Specific

○ Addresses ACE2 use

○ Addresses interferon concern

○ Addresses lipid envelope

● General anti-viral or anti-microbial

● General immune-supporting

supplement ingredients

Goldenseal

L-lysine

Mushrooms

N-Acetyl-Cysteine*

Oregano

Astragalus

Copper*

Echinacea*

Elderberry*

Garlic (Allicin)

Probiotics

Quercetin

Vitamin C*

Vitamin D

Zinc*

*Primary

● Immunomodulatory, anti-inflammatory,

anti-viral, anti-oxidant, and

cardioprotective activities 1

● Promotes recovery from viral infection and

prevents viral replication 2

● Influenza, 3 myocarditis induced by viral

infections, 4 chronic viral hepatitis B, 5 viral

herpes simplex keratitis 6

1. Zhuang, Z., et al. (2019). Astragaloside IV exerts cardioprotection in animal models of viral myocarditis: A preclinical systematic review and meta-analysis.

2. McCulloch, M., et al. (2002). Chinese herbal medicine and interferon in the treatment of chronic hepatitis B: A meta-analysis of randomized, controlled trials.

3. Liang, Y. et al. (2019). Astragalus Membranaceus Treatment Protects Raw264.7 Cells from Influenza Virus by Regulating G1 Phase and the TLR3-Mediated Signaling Pathway..

4. Huang, Z.Q., et al. (1995). Effect of Astragalus membranaceus on T-lymphocyte subsets in patients with viral myocarditis.

5. Tang, L.L., et al. (2009). Clinical and experimental effectiveness of Astragali compound in the treatment of chronic viral hepatitis B.

6. Mao, S.P., et al. (2004). Modulatory effect of Astragalus membranaceus on Th1/Th2 cytokine in patients with herpes simplex keratitis.

● Contact with copper shown to inactivate

human coronavirus 229E and SARS-COV

in vitro 1 2

● Concomitant zinc intake may limit copper

absorption, but zinc:copper ratios of 2:1,

5:1 or 15:1 may not reduce absorption in

humans 3, 4

1. Warnes, S. L. et al. (2015). Human coronavirus 229E remains infectious on common touch surface materials.

2. Han, J. et al. (2005). Efficient and quick inactivation of SARS coronavirus and other microbes exposed to the surfaces of some metal catalysts.

3. August, D. et al. (1989). Determination of zinc and copper absorption at three dietary Zn-Cu ratios by using stable isotope methods in young adult and elderly subjects.

4. Trumbo, P. et al. (2001). Dietary reference intakes: vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon,

vanadium, and zinc

● May ↑ immune cell counts (WBCs, monocytes,

neutrophils, NK cells)

● May increase the suppression free radical

production production in the later-phase of the

cold by neutrophils 1

● May ↓ the risk of common cold development by

10-58%, and days with cold by approximately a

day and a half 2 3

● May ↓ the incidence of cumulative viral infections

by 26% and recurring infections (influenza virus

and parainfluenza virus) by 59% 41. Goel, V., et al. (2005). A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold.

2. Shah, S.A., et al. (2007). Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis.

3. Karsch-Völk, M., et al. (2014). Echinacea for preventing and treating the common cold.

4. Jawad, M., et al. (2012). Safety and Efficacy Profile of Echinacea purpurea to Prevent Common Cold Episodes: A Randomized, Double-Blind, Placebo-Controlled Trial.

● Highly effective against HCoV-NL63 1

● Anti-viral and immune-stimulating

properties (e.g., anthocyanins)

● ↓ symptoms of viral URTIs, particularly for

the influenza virus 2

● ↓ symptoms of cold and flu, duration of

infection 3 4

1. Weng, J.-R. et al. (2019). Antiviral activity of Sambucus FormosanaNakai ethanol extract and related phenolic acid constituents against human coronavirus NL63.

2. Hawkins, J., et al. (2019). Black elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: A meta-analysis of randomized, controlled

clinical trials.

3. Tiralongo, E., et al. (2016). Elderberry Supplementation Reduces Cold Duration and Symptoms in Air-Travellers: A Randomized, Double-Blind Placebo-Controlled

Clinical Trial.

4.Zakay-Rones, Z., et al. (2014). Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections.

● Daily 2.5g of garlic extract may reduce

severity of cold and flu 1

● Can reduce incidence of viral challenge

and days of cold and flu sickness 2 3

● Increases macrophage activity, and

proliferation of natural killer cells, and T

and B cells 1, 4

1. Percival, S. S. (2016). Aged garlic extract modifies human immunity.

2. Nantz, M. P., et al. (2012). Supplementation with aged garlic extract improves both NK and γδ-T cell function and reduces the severity of cold and flu symptoms: a randomized, double-blind, placebo-controlled nutrition intervention.

3. Josling, P. (2001). Preventing the common cold with a garlic supplement: a double-blind, placebo-controlled survey.

4. Ried, K. (2016). Garlic lowers blood pressure in hypertensive individuals, regulates serum cholesterol, and stimulates immunity: an updated meta-analysis and review

● Research limited to in vitro and animal

studies 1

● Inhibition of influenza A and inflammatory

markers in vitro 2

● Anti-microbial activity against

methicillin-resistant Staphylococcus

aureus and Helicobacter pylori in vitro 3 4

● Berberine: Anti-viral, anti-influenza

properties 5

1. NIH. (2016). Goldenseal.

2. Cecil, C.E., et al, (2011). Inhibition of H1N1 influenza A virus growth and induction of inflammatory mediators by the isoquinoline alkaloid berberine and extracts of goldenseal (Hydrastis canadensis).

3. Cech, N.B., et al. (2012). Quorum quenching and antimicrobial activity of goldenseal (Hydrastis canadensis) against methicillin-resistant Staphylococcus aureus (MRSA).

4. Cwikla, C., et al (2010). Investigations into the antibacterial activities of phytotherapeutics against Helicobacter pylori and Campylobacter jejuni.

5. Yan, Y.Q., et al. (2018). Anti-influenza activity of berberine improves prognosis by reducing viral replication in mice..

● Most studied for its uses in herpes simplex

virus infections 1

● May reduce bacterial and viral diarrhea

episodes and days of sickness in children,

and reduce the number of days with

sickness and number of episodes of coryza

in men.

● Supplementation may decrease serum

ferritin and CRP levels in women 2

1. Singh, M., et al. (2011). Medicinal Uses of L-Lysine: Past and Future.

2. Ghosh, S., et al, (2010). Effect of lysine supplementation on health and morbidity in subjects belonging to poor peri-urban households in Accra, Ghana.

● Used in TCM for their immune-stimulating,

anti-microbial, anti-fungal, anti-tumor, and

anti-viral properties 1

● In vitro studies: broad anti-viral effects

(e.g., against influenza), using a variety of

mushroom extracts: Ganoderma lucidum,

Lentinus edodes, Grifola frondosa,

Agaricus brasiliensis, 2 3 Phellinus

igniarius, 4 Rozites caperata 5

1. Zhou, R., et al. (2019). Research Progress of Bioactive Proteins from the Edible and Medicinal

Mushrooms.

2. Eguchi, N., et al. (2017). In vitro Anti-Influenza Virus Activity of Agaricus brasiliensis KA21.

3. Avtonomova, A.V., & Krasnopolskaya, L.M. (2014). Antiviral properties of basidiomycetes metabolites.

4. Lee, S., et al. (2013). The anti-influenza virus effect of Phellinus igniarius extract.

5. Piraino, F., & Brandt, C.R. (1999). Isolation and partial characterization of an antiviral, RC-183, from the edible mushroom

Rozites caperata.

● 600 mg once or twice per day may

attenuate influenza-like episodes, severity,

and length 1 2

● Mucolytic agent preventative effect in

other disorders of the lung such as chronic

bronchitis or COPD 3 4

1. De Flora, S. et al.(1997). Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment.

2. Lai, K. et al. (2010). High-dose N-acetylcysteine therapy for novel H1N1 influenza pneumonia.

3. Wei, J. et al.(2019). Effect of Orally Administered N-Acetylcysteine on Chronic Bronchitis: A Meta-analysis. Advances in therapy

4. Cazzola, M .et al (2017). Impact of mucolytic agents on COPD exacerbations: a pair-wise and network meta-analysis..

● Essential oils used for their anti-microbial,

anti-viral, and anti-fungal properties 1

● In vitro studies: assessed the anti-viral

activity against certain viruses (e.g., murine

norovirus, RSV, CVB3, and HSV-1) 2 3

1. Leyva-López, N., et al. (2017). Essential Oils of Oregano: Biological Activity beyond Their Antimicrobial Properties.

2. Zhang, X.L., et al. (2014). Phenolic compounds from Origanum vulgare and their antioxidant and antiviral activities.

3. Gilling, D.H,, et al. (2014). Antiviral efficacy and mechanisms of action of oregano essential oil and its primary component carvacrol against murine norovirus.

● Anti-microbial effects by competition

● Benefits immune function by promoting a health composition of bacteria in the GI tract

● Improved regulation of anti-inflammatory and pro-inflammatory cytokines, anti-oxidative biomarkers 1

● May reduce cold severity and have minor effects on cold prevention 2

● May improve influenza vaccination efficacy 3

● May reduce rates of respiratory tract infections in adults and children 4 5

● 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) 6

1. Md. Abul Kalam Azad, et al. (2018). Immunomodulatory Effects of Probiotics on Cytokine Profiles.

2. Kang, E.J., et al. (2013). The effect of probiotics on prevention of common cold: a meta-analysis of randomized controlled trial studies.

3. Davidson, L.E.., et al. (2011). Lactobacillus GG as an immune adjuvant for live-attenuated influenza vaccine in healthy adults: a randomized

double-blind placebo-controlled trial.

4.Araujo, G.V., et al. (2015). Probiotics for the treatment of upper and lower respiratory-tract infections in children: systematic review

based on randomized clinical trials.

5. Hao, Q., et al. (2015). Probiotics for preventing acute upper respiratory tract infections..

6. Carter, G.M., et al. (2016), Probiotics in Human Immunodeficiency Virus Infection: A Systematic Review and Evidence Synthesis of

Benefits and Risks.

● Anti-microbial, improved anti-oxidant capacity

● Often used for the common cold and flu

● Maintenance dose to boost immunity: 200 mg in children and 1 g of vitamin C per day in adults

● Common cold: 1 to 2 g in children and 3 to 4 g in adults at the onset of symptoms can reduce the duration of infection 1 2

● Reduces the incidence and severity URTIs

○ 1000 mg per day: reduction of symptom severity and sick days, particularly in 40+ 3

● In vitro and mice studies

○ Protection against ebola viruses 4

○ Anti-viral properties against influenza, Mayaro, Chikungunya, Epstein-Barr, and Hepatitis C viruses 5 6 7 8

9

Vitamin C + Quercetin: synergistic effects for immune-boosting activity by reducing oxidative stress and DNA damage

1. Ran, L., et al. (2018). Extra Dose of Vitamin C Based on a Daily Supplementation Shortens the Common Cold: A Meta-Analysis of 9

Randomized Controlled Trials.

2. Hemilä, H,, & Chalker, E. (2013). Vitamin C for preventing and treating the common cold.

3. Heinz, S.A., et al. (2010). Quercetin supplementation and upper respiratory tract infection: A randomized community clinical trial.

4. Qiu, X., et al. (2016). Prophylactic Efficacy of Quercetin 3-β-O-d-Glucoside against Ebola Virus Infection.

5. Lee, M., et al. (2015). Quercetin-induced apoptosis prevents EBV infection.

6. Lani, R., et al. (2015). Antiviral activity of silymarin against chikungunya virus.

7. Kim, Y., et al. (2010). Inhibition of influenza virus replication by plant-derived isoquercetin.

8. Khachatoorian, R., et al. (2012). Divergent antiviral effects of bioflavonoids on the hepatitis C virus life cycle.

9. dos Santos, A.E., et al. (2014). Quercetin and quercetin 3-O-glycosides from Bauhinia longifolia (Bong.) Steud. show anti-Mayaro virus

activity.

● Modulation of the immune system 1

● Deficiencies have been linked to a variety of viral infections 2 3 4

● Prevention and/or treatment of URTI in children and adults 5

● Adjunct to other anti-viral therapies may have synergistic benefits in infections such as chronic hepatitis C and HIV 6 7

● Protective effect against the common cold

● Improves the anti-inflammatory and anti-oxidant profile 8 9

● Reduces pro-inflammatory cytokines such as TNF-ɑ and many interleukins, and biomarkers of oxidative stress 10

1. Chang, S.W., et al. (2019). Vitamin D and health - The missing vitamin in humans.

2. Pletz, M.W., et al. (2014). Vitamin D deficiency in community-acquired pneumonia: low levels of 1,25(OH)2 D are associated with disease severity.

3. Villar, L.M., et al. (2013). Association between vitamin D and hepatitis C virus infection: a meta-analysis.

4. Hu, Y.C., et al. (2019). Low vitamin D levels are associated with high viral loads in patients with chronic hepatitis B: a systematic review and meta-analysis.

5. Charan, J., et al. (2012). Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis.

6. Eckard, A.R., et al. (2018). Vitamin D supplementation decreases immune activation and exhaustion in HIV-1-infected youth.

7. Kim, H.B., et al. (2018). Efficacy of vitamin D supplementation in combination with conventional antiviral therapy in patients with chronic hepatitis C infection: a meta-analysis of randomised controlled trials.

8. Prasad, A.S., et al. (2008). Duration and severity of symptoms and levels of plasma interleukin-1 receptor antagonist, soluble tumor necrosis factor receptor, and adhesion molecules in patients with common cold treated with zinc acetate.

9. Prasad, A.S., et al. (2007). Zinc supplementation decreases incidence of infections in the elderly: effect of zinc on generation of cytokines and oxidative stress.

10. Kirchberger, S., et al. (2007). Modulation of the Immune System by Human Rhinoviruses.

● Maintenance dose: 1 g, once per day

● Common cold: 3 to 4 g, once per day at the onset of the common cold symptoms for the duration of the cold in adults

● 400 mg, once per day, minimum 8-16 weeks in healthy adults as a preventative measure

● Prevention: 0.9 ml, three times per day (equivalent to 2400 mg of extract), minimum 4 months

● Acute: Up to 4.5 ml liquid extract (equivalent to 4000 mg), once per day at the first stage of cold development

● 75-100 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 cold

Common cold:

● 1 billion CFU of L. paracasei 8700:2 (DSM 13434) & L. plantarum HEAL 9 (DSM 15312), once per day for 3 months

Influenza:

● 10 billion CFU of L. fermentum CECT5716, once per day for 2 weeks before influenza vaccination and two weeks after

● 10 billion CFU of L. rhamnosus GG, twice per day for 4 weeks after influenza vaccination

● 500 mg of S. cerevisiae (EpiCor®), once per day for 12 weeks

● COVID-19: what you need to know

● Protocols

○ Cold and flu

○ Respiratory care

● How to communicate with patients about COVID-19

● How to prepare your practice for a potential lockdown

● COVID-19 patient handout

● Immune support patient handout

● Where to find credible and trustworthy information about COVID-19

● Immune support: a comprehensive guide for patients

immune support resourcesImmunity

● Keep Your Immune System Strong, Naturally

● Top 20 Immune Boosting Foods

Diet

● Nutritional and Balanced Diets: Their Role in Your Health

● The Many Health Benefits Of The Mediterranean Diet

Exercise

● The Important Mental Health Benefits of Exercise & Fitness

Stress

● Healthy Reasons and Tips to Incorporate Mindfulness Every Day

Sleep

● Natural Sleep Aid: Lifestyle Tips & Supplements

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