It seems as though every conversation I had this week included references to the coronavirus—whether to get worried, what to do if it reaches Minnesota, and—as of March 6^th, what to do about it now that it is here.

COVID-19 is more than just a garden-variety viral infection.  Its mortality rate—especially for older people and those with underlying illnesses—is probably around 1-3%. (By comparison, influenza’s mortality rate is closer to 0.1%.)  One of the reasons it’s hard to know the exact rate is that it’s not a severe illness for younger people and the number of cases is probably much higher than recorded.   About 80% of the cases are mild—cough, fever—and I suspect that some people who have it don’t even know they have something besides a cold.  The lack of severe symptoms, couple with the fact that people can be infectious before they feel sick makes person-to-person spread more likely.  And it doesn’t help that the virus appears to live on hard surfaces for up to 48 hours.

While the conventional medical world has emphasized handwashing and other public health measures, it has not offered much else in the way of prevention.  This surprises me as my integrative medicine sources have been buzzing with natural strategies.

To be sure, hygiene and avoidance are critical.  But you may be surprised to know that a tremendous amount of research has been done on natural treatments for pandemic-causing infections including the coronavirus family.  I have compiled a short list of evidence-based interventions to keep you healthy.  None of these are very expensive and all of them are safe.  I hope this helps you move past raw fear to empowerment and courage.

General Measures

The most important thing you can do to stay well is to keep your immune system strong.   Eat a healthy diet with as many vegetables and as little added sugar and alcohol as possible. 

Smoking appears to increase the risk of a more severe infection—27% versus 3% in one Singapore study,[1] so if you need yet another reason to quit smoking, this is it.

Get enough sleep; sleep deprivation dramatically weakens your immune system.[2],[3]  

While regular moderate exercise is immune-enhancing, intensive exercise can reduce immunity[4] so this may not be the year to train for a marathon. 

Supplements

In terms of supplements, my favorite is vitamin D.  We think of vitamin D as enhancing bone strength (which it does) but its effects on the immune system are significant, particularly for viral infections.[5],[6],[7]  Checking your vitamin D level and keeping it at least above 50 ng/ml is an easy step you can take to boost immunity.  The daily allowance recommended  by the Institute of Medicine for vitamin D is 400 international units (IU) for children up to age 12 months, 600 IU for ages 1 to 70 years, and 800 IU for people over 70 years. This is woefully inadequate and not supported by the evidence.[8]  The Endocrine Society recommends somewhat higher levels. 1500–2000 IU/day for adults, though they found that obese adults required 2–3 times more vitamin D to sustain a blood level of at least 30 ng/ml.   In my experience, even this higher dose is inadequate.  Researchers who have actually measured vitamin D levels have found that even 2000 IU a day does not maintain levels in even the normal range, let alone in the optimal range.[9]   In my professional experience, most people need at least 5000 IU a day during the winter to maintain these levels. If you can’t get your level checked, this is a pretty safe dose.  In fact, much higher doses than that have been found to be safe.[10]  The only contraindication for high dose vitamin D is sarcoidosis.

Zinc is essential for approximately 2000 enzymatic actions in the human body and its role in immune function is well-known.[11]  Zinc deficiency is not uncommon and particularly affects the elderly, vegans/vegetarians, and individuals with chronic disease such as inflammatory bowel disease.[12]  There is evidence that zinc supplementation may reduce viral infections.[13],[14] I recommend taking 15-30 mg. a day, and balancing it with copper 2 mg. to avoid a copper deficiency. Check any multivitamins, mineral or other combination supplements to make sure you don’t go above about 40 mg. a day.

Our understanding of our gut microbiome’s role in infection is evolving.  There is evidence that live and even killed probiotics can strengthen the response to viral infections.[15],[16],[17] Probiotics are an easy, safe and inexpensive intervention.  I recommend a multi-strain product with at least 20 billion CFU’s purchased from a reputable source such as a food co-op or Whole Foods.

Despite its reputation, the evidence for vitamin C for prevention of the common cold and other viruses is weaker. However, there is a trend toward protection in studies where participants were intentionally exposed to cold viruses and the duration of the infection seems to be shorter.[18]  This seems particularly true if you are already taking vitamin C and increase the dose when you get sick.[19]  Given its safety and low cost, taking at least 1000 mg. and probably more like 2000-3000 mg. a day for prevention can’t hurt.  The only real risk is of looser stools which can be eliminated with lowering the dose.

The most effective immune boosters in the plant world are mushrooms. They have been used for millennia in Chinese medicine[20] and in Eastern European traditional remedies.  Much of the research so far has shown activity in the test tube,[21],[22],[23] but there is evidence of effectiveness in humans as well. [24]  Each mushroom species hasdiffering properties and they may be synergistic.[25]  Your best bet may be to take a combination product such as those sold by  Fungi Perfecti (https://fungi.com/collections/host-defense-extracts) or Mushroom Wisdom (http://www.mushroomwisdom.com/).  These supplements are more expensive than the preceding recommendations, so if you are relatively low risk for serious illness, you may want to balance cost against protection.

Herbs are amazing defenses against any type of infection. They contain not just antibacterial and antiviral properties but many are immune-enhancing and anti-inflammatory, and are synergistic with each other and antibiotics.[26],[27]  A number of western herbal therapies have been used for fighting viral infections.  The list of options is huge, so I will just offer one. There is evidence for the effectiveness of elderberry in particular against other strains of coronavirus.[28],[29],[30],[31]  A preventive adult dose is a tablespoon of elderberry syrup or once capsule once a day. Reputable brands include Sambucol liquid or black elderberry capsules by Nature’s Way.  You can also make a tea or just eat elderberries.

I hope that you will find these recommendations useful and encouraging.  Please feel free to share it with others; I just ask that you credit me for it. And please send me your feedback!

Yours in health,

Laurie

[1] Liu W et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease [published online ahead of print, 2020 Feb 28]. Chin Med J (Engl). 2020;10.1097

[2] Besedovsky L et al. The Sleep-Immune Crosstalk in Health and Disease. Physiol Rev 2019; 99:1325-1380.  Full text available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689741/.

[3] Prather AA et al.  Behaviorally assessed sleep and susceptibility to the common cold. Sleep 2015; 38:1353-1359.

[4] Simpson RJ et al. Exercise and the regulation of immune functions. Prog Mol Biol Transl Sci 2015; 135:355-380.

[5] Martineau AR et al.  Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ  2017;  356: i6583.

[6] Beard J et al. Vitamin D and the anti-viral state. J Clin Virol 2011; 50:194-200.

[7] Edlich RF et al.  Pandemic preparedness for swine flu influenza in the United States. J Env Pathol, Toxicol and Oncol 2009; 28:261-264 (editorial).

[8] Vieth R and Holick MF. Chapter 57B- The IOM-Endocrine Society controversy on recommended vitamin D targets: In support of the Endocrine Society Position. Vitamin D 4th Edition Volume 1: Biochemistry, Physiology and Diagnostics.   pages 1091-1107. Academic Press, 2018.

[9] Sadat-Ali M et al. Maintenance Dose of Vitamin D: How Much Is Enough? J Bone Metab  2018; 24:161-164.

[10] Kimball SM et al. Safety of vitamin D3 in adults with multiple sclerosis. Am J Clin Nutr 2007; 86:645-651.

[11] Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr. 1998;68(2):447s–63s.

[12] Siva S et al. Zinc deficiency is associated with poor clinical outcomes in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2017;23(1):152–7.

[13] Allan GM and Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014; 186: 190–199.

[14] Read SA et al. The role of zinc in antiviral immunity. Advances in Nutrition, 2019; 10: 696–710.

[15] Allan GM and Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014; 186: 190–199.

[16] Hao Q et al. Probiotics for preventing acute upper respiratory tract infections. Cochrane Database Syst Rev. 2011 Sep 7; (9):CD006895.

[17] Kanauchi O et al.  Probiotics and paraprobiotics in viral infection: Clinical application and effects on the innate and acquired immune systems.  Curr Pharm Des 2018; 24:710-717.

[18] Allan GM and Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014; 186: 190–199.

[19] Ran L, Zhao W, Wang J, et al. Extra Dose of Vitamin C Based on a Daily Supplementation Shortens the Common Cold: A Meta-Analysis of 9 Randomized Controlled Trials. Biomed Res Int. 2018;2018:1837634.

[20] Aung SK: The Clinical Use of Mushrooms from a Traditional Chinese Medical Perspective. 2005, 7(3):375–376.

[21] Eguchi N et al. In-vitro anti-influenza virus activity of agaricus brasiliensis KA21. Biocontrol Sci 2017; 222:171-174.

[22] Ellan K.  Anti-viral activity of culinary and medicinal mushroom extracts against dengue virus serotype2: An in-vitro study. BMC Complement Altern Med 2019; 19:260.

[23] Benson, K.F. et al. The mycelium of the Trametes versicolor (Turkey tail) mushroom and its fermented substrate each show potent and complementary immune activating properties in vitro. BMC Complement Altern Med 19, 342 (2019).

[24] Nishihira J et al. Maitake mushrooms (Grifola frondosa) enhances antibody production in response to influenza vaccination in healthy adult volunteers concurrent with alleviation of common cold symptoms. Functional Foods in Health and Disease 2017; 7: 462-482.

[25] Wang L and Hou Y. Determination of trace elements in anti-influenza virus mushrooms. Biol Trace Elem Res  2011; 143:1799-1807.

[26] Aiyegoro OA and Okoh AI.  Use of bioactive plant products in combination with standard antibiotics: implications in antimicrobial chemotherapy.  J Medicinal Plants Res 2009; 3:1147-1152.

[27] For a well-researched and comprehensive review of herbs see Buhner SH. Herbal Antibiotics: Natural Alternatives for Treating Drug-Resistant Bacteria, Second Edition. North Adams, MA 2012. Storey Publishing.

[28] Chen C et al.  Sambucus nigra extracts inhibit infectious bronchitis virus at an early point during replication. BMC Vet Res. 2014; 10: 24. 

[29] Zakay-Rones Z et al. Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract (Sambucus Nigra L.) During an Outbreak of Influenza B Panama. J Alt Complement Med 1995 1:361-369.

[30] Weng JR et al. Antiviral activity of Sambucus FormosanaNakai ethanol extract and related phenolic acid constituents against human coronavirus NL63. Virus Res. 2019;273:197767.

[31] Zakay-Rones Z et al. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections. J Int Med Res 2004; 32:132-140.      

By Laurie Radovsky, MD

When I was in medical school, I learned that antibiotics were like the Knight in shining armor who saved the Princess (the body) from the evil Dragon (infection). It is true that antibiotics can be lifesaving, and have transformed not just the practice of medicine, but human society. At the same time, antibiotics alone are not what keep infections from being fatal. Think of someone who is radically immunosuppressed, such as with a bone marrow transplant. Even a relatively weak germ can kill them. In other words, the body’s own immune system must take a role in fighting off the infection. While the Knight has to wound and distract the Dragon, the Princess needs to take out her own sword to kill it.

I have written before about the importance of lifestyle in chronic illness: diet, sleep, exercise, and stress management. Diabetes cannot be managed without a low-glycemic diet and exercise. Depression and anxiety cannot be controlled without adequate sleep and a diet that provides the precursors to neurotransmitters. These four areas are also essential in the management of persistent Lyme disease.

Diet: To quote Terri Guillemets, “If you plant Twinkies in your body garden, how do you expect to harvest health?” Your immune system requires a low-sugar diet high in a rainbow of vegetables and adequate protein to function properly. I’ll write a separate blog on nutrition and Lyme in the future.

Exercise/pacing: in other conditions, I usually work with patients to increase their physical activity. For patients with Lyme disease, I often do the opposite: they are usually overdoing it. Sometimes patients have to work to support their families and to maintain their health insurance. Mots of us feel like we “should” be doing more—more laundry, more paid work, more parenting. But we only have so much energy, and if we try to push past these limits, we crash. This is probably the hardest of the lifestyle changes. Unfortunately, it is also the most important. If you do not respect the limits of your energy, not enough energy is left for healing.

Sleep: The immune system requires adequate sleep in order to function effectively. It is crucial for you to dedicate enough time to sleep. You might have gotten away with 6 hours of sleep a night before you got sick. That’s probably not enough now. Some patients need 12 hours of sleep. Listen to your body and invest enough time in sleep.

To complicate the sleep issue, insomnia and frequent waking are symptoms of tick-borne illness, particularly Bartonella. We can work aggressively to overcome these with sleep hygiene, guided imagery, supplements, and prescriptions if needed.

Stress management: too much cortisol from the “fight or flight” reaction will undermine your immune system. Being ill is stressful, bringing worries about finances and relationships. It is essential that you learn to cope with stress. Many patients benefit from counseling with a sympathetic therapist. Guided imagery, mindfulness meditation, and other therapies such as HeartMath can help as well. We can direct you to stress management options within our office and beyond.

Your Princess has a sword. Make sure that she is strong enough to use it to free you from the Dragon of tick-borne illness.

MYTH: You can only have Lyme disease if you live in a few areas of the country.

TRUTH: Lyme disease has been reported in all states of the union. Some of this is due to residents acquiring the infection elsewhere, but the range of infected ticks is much larger than previously believed, and is growing. Ticks associated with carrying Lyme disease have now been identified in almost 50% of counties in the United States.[1] Furthermore, migrating songbirds carry infected ticks, spreading them across their migration route.[2]

MYTH: You can only get Lyme disease during the warmest part of the summer.

TRUTH: It is true that the greatest risk of getting bitten by a tick is between May, when nymphs hatch, and July. However, any time when the temperature is above freezing, ticks can be active.[3]  Ticks are active well into the fall, so deer hunters are at risk.

MYTH: You can only get Lyme disease if you go into the woods.

TRUTH: As human environments encroach on the wild, the interface between suburbs and the habitat of deer and other animals increases. As noted above, songbirds such as robins carry infected ticks and can deposit them in urban yards as they search for worms in lawns. Pets such as dogs and cats can also bring infected ticks into the home.

MYTH: You can only have Lyme disease if you have a known tick bite.

TRUTH: Only about one third of people with documented Lyme disease recall a tick bite.[4]

MYTH: You can only have Lyme disease if your tick has been attached at least 72 hours.

TRUTH: Transmission rates increase with increasing time of attachment, but there is no definitive cutoff for a safe time. The concept that transmission takes 72 hours may come from the idea that the tick has to regurgitate its stomach contents into the wound. We now know that Borellia is present in the tick salivary gland, so transmission may be rapid. A 2015 review article summarizes numerous animal studies showing infection of most animals by 72 hours, and of case reports citing infection within 6 hours or less of humans.[5] Added to this is the difficulty in knowing how long a very small tick has been attached, as the bite is painless and may go unnoticed.  Other tick-borne infections can also be transmitted quickly. Anaplasma can be transmitted in a matter of a few hours of tick attachment.[6]

MYTH: You can only have Lyme disease if you have the classic bull’s-eye rash.

TRUTH: Estimates of how many Lyme patients have a rash ranges from a low of 27% to a high of 80%.[7] In one study, only 20% of cases was the bull’s-eye rash present.[8]

MYTH: You can only have Lyme disease if your Lyme test is positive.

TRUTH: Multiple studies have shown the two-tiered test for Lyme (ELISA followed by a Western blot) to have extremely high false-negative rates.[9] [10] [11] [12] This is because the test measures our immune response to the bacteria, and Borellia is masterful at disguising itself and changing its outer surface proteins to evade detection.[13]

MYTH: You should wait until the results of your lab tests for Lyme come back to start antibiotics.

TRUTH: An animal model of infection suggests that the sooner antibiotics are started, the more likely the infection will be prevented.[14] Given the high false-negative rate, a negative test result does not mean that you don’t have the infection—so why wait for it? Even Up to Date, a conventional source of online information for physicians, says, “There is no benefit of blood testing for Lyme disease at the time of the tick bite; even people who become infected will not have a positive blood test until approximately two to six weeks after the infection develops (post-tick bite).”[15]

MYTH: If you do start antibiotics, you should stop them if the results of your lab tests for Lyme come back negative.

TRUTH: See above. This is especially true if you are feeling better on antibiotics.

MYTH: A single dose of doxycycline is adequate treatment for acute Lyme disease.

TRUTH: Not only is the evidence for effectiveness of a single dose of doxycycline weak, but there is evidence that this may actually decrease the immune response to the infection, causing seronegative infection (where the immune system does not make antibodies, so the patient looks like they do not have the disease).[16]

MYTH: A 10-day course of antibiotics is adequate treatment for acute Lyme disease.

TRUTH: While the longer someone is on antibiotics, the more risk of side effects they have, failure rates of shorter courses are unacceptably high.[17]

MYTH: If you are still feeling sick at the end of your course of antibiotics, you should still stop them.

TRUTH: Many patients require longer courses of antibiotics, and stopping antibiotics while a patient is still having symptoms increases the risk of relapse.[18]

MYTH: If you have had one course of antibiotics and still have symptoms, the symptoms are not due to persistent infection.

TRUTH: More and more evidence is mounting that patients can be persistently infected with Lyme bacteria. One study on primates found evidence of Borellia genetic material in ¾ of the monkeys treated with antibiotics previously.[19] Another study had uninfected ticks feed on patients who had been treated but still felt unwell. Genetic material from Lyme bacteria was recovered from one of these patients. In yet another study, patients with ill-defined symptoms who had already been treated with antibiotics were found to have positive Borellia cultures.[20] It is unfortunate that politics has impeded changes in the way we treat patients for acute and chronic Lyme disease.

Footnotes:

[1] Eisen RJ et al. County-Scale Distribution of Ixodes scapularis and Ixodes pacificus (Acari: Ixodidae) in the Continental United States. Journal of Medical Entomology, 2016, 1–38

[2] Scott JD et al. Widespread dispersal of Borrelia burgdorferi-infected ticks collected form songbirds across Canada. J. Parasitol., 98(1), 2012, pp. 49–59

[3] http://pennstatehershey.adam.com/content.aspx?productId=10&pid=10&gid=000016

[4] http://www.uptodate.com/contents/what-to-do-after-a-tick-bite-to-prevent-lyme-disease-beyond-the-basics. Accessed February 3rd, 2016.

[5] Cook MJ. Lyme borreliosis: a review of data on transmission time after tick attachment. International Journal of General Medicine 2015; 8:1-8.

[6] Thomas RJ, Dumler JS, Carlyon JA. Current management of human granulocytic

anaplasmosis, human monocytic ehrlichiosis and Ehrlichia ewingii ehrlichiosis.

Expert Rev Anti Infect Ther. 2009;7(6):709-722.

[7] https://www.lymedisease.org/lymepolicywonk-how-many-of-those-with-lyme-disease-have-the-rash-estimates-range-from-27-80-2. Accessed February 3rd, 2016.

[8] Tibbles CD, Edlow JA. Does this patient have erythema migrans? JAMA. 2007; 297(23):2617-27.

[9] Durovska J et al. Our experience with examination of antibodies against antigens of Borrelia burgdorferi in patients with suspected Lyme disease. Bratisl Lek Listy. 2010;111(3):153-5.

[10] Kaiser R.  False negative serology i patients with neuroborreliosis and the value of employing of different borrelial strains in serological assays.  J Med Microbiol 2000; 49(10): 911-915.

[11] Wojciechowska-Koszko et al. Serodiagnosis of Borreliosis: Indirect Immunofluorescence Assay, Enzyme-Linked Immunosorbent Assay and Immunoblotting. Arch. Immunol. Ther. Exp. 2011; 59:69-77;

[12] Ang CW et al. Large differences between test strategies for the detection of anti-Borrelia antibodies are revealed by comparing eight ELISAs and five immunoblots. Eur J Clin Microbiol Infect Dis. 2011; 30:1027-1032

[13] Liang FT et. Al. Borrelia burgdorferi Changes Its Surface Antigenic Expression in Response to Host Immune Responses

INFECTION AND IMMUNITY 2004; 72:5759–5767.

[14] Cook MJ. Lyme borreliosis: a review of data on transmission time after tick attachment. Int J General Med 2015; 8:1-8.

[15] http://www.uptodate.com/contents/what-to-do-after-a-tick-bite-to-prevent-lyme-disease-beyond-the-basics. Accessed February 3rd, 2016.

[16] Cameron DJ et al. Evidence Assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev, Anti Infect. Ther. 2014; 12(9):1103-35

[17] Cameron DJ et al. Evidence Assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev, Anti Infect. Ther. 2014; 12(9):1103-35

[18] Cameron DJ et al. Evidence Assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev, Anti Infect. Ther. 2014; 12(9):1103-35

[19] Embers ME et. Al. Dynamic Longitudinal Antibody Responses during Borrelia burgdorferi Infection and Antibiotic Treatment of Rhesus Macaques. Clinical and Vaccine Immunology 2012; 19:1218–1226

[20] Rudenko N et al. Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. Clin Microbiol Infect. 2015 Dec 8. pii: S1198-743

When practicing medicine is like playing with a Shape-O toy, and what to do about it.

You have probably seen this toy before. It’s the Tupperware Shape-O, a tool for teaching toddlers how to match shapes to the holes they fit in. It reminds me of how new doctors learn to recognize illnesses based on their characteristics. Sore throat, fever, swollen glands: ah, that’s strep throat! Fatigue, weight gain, constipation, feeling cold—must be hypothyroidism! With as much enthusiasm and delight as a young child finding the right hole into which to insert the triangle or the square, we learned in medical school to recognize the patterns that would lead to a successful diagnosis. (more…)