The WHO is testing the antiviral activity of herbal medicines against Coronavirus (COVID-19). These herbal targets warrant furture research.
Coronaviruses are one cause of the common cold (1). Severe acute respiratory syndrome (SARS-CoV) and the Middle East respiratory syndrome (MERS-CoV) are both coronaviruses (2). Whilst research is being conducted to find pharmaceutical therapeutics for coronavirus, the elusive search for the cure to the common cold is a well known. Nonetheless there have been drugs used in SARs and MERs and the pharmaceutical actions can direct us to herbal actions that have been demostarted n in-vitro and in-vivo studies to inhibit coronavirus.
In an ideal world we would isolate the sick and old on an island while the coronavirus was allowed to run its course naturally amongst the healthy population, after which when herd immunity was achieved the virus would be unable to infect further hosts, the vulnerable could safely return. Herd immunity describes natural immunity. The term has been adopted by the pharmaceutical industry to describe the effects of artificial immunity through vaccination. Herd immunity can be achieved by either exposure to a disease or vaccination. Individuals, who are immune to a disease act as a barrier in the spread of disease, slowing or preventing the transmission of disease to others, hence protect the vulnerable. An individual's immunity can be acquired through artificial immunity via vaccination or through natural infection (3). The herd immunity level (HIL), is the percentage at which the disease may no longer persist in the population, putting an end to the pandemic. The herd immunity level for SARs was 50%-80% (4). Regardless of fast tracking vaccine research, the fact is that no vaccine will be ready for this current outbreak. Natural herd immunity is not an option, it is the only option.
Read about past difficulties with coronavirus vaccine research in Coronavirus (COVID-19) Lockdown; How Long will it Last?
This concept of promoting natural herd immunity was expressed by Sir Patrick Vallance FRS FMedSci FRCP and Government Chief Scientific Adviser (GCSA), who says coronavirus may become an annual event and that Britain needs herd immunity to combat the spread of Covid-19 (3). Professor of Infectious Disease Modelling Graham Medley at the London School of Hygiene and Tropical Medicine also agreed and explained why the Government is trying to actively promote herd immunity by allowing schools to stay open (4). It must be stressed that both experts said at the same time we have to shield the vulnerable and we can do this by taking common sense measures, such as limiting visits and acting like we have the virus when we do.
The UK approach is unique and has received much criticism. The outcomes of the current UK strategy to leave schools open for that short time only will eventually be known by comparing the deaths rates of countries who took different approaches. If this is indeed "the big one", history has shown us that coronavirus will likely come in waves and the UK government's strategy also serves to better prepare the UK for the next wave. A vaccine is of no use when herd immunity is achieved.
To learn which countries are more accepting of the inevitably of COVID-19 to overwhelm health systems and the concurrent need to protect the economy read also Coronavirus (COVID-19) Countries Adopting Herd Immunity
It is that 80% expected to be infected with corona virus (5). To put this into perspective, 80% of global population is 6,240,000,000. In words that is six billion two hundred and forty million people. “Globally, about 3.4% of reported COVID-19 cases have died,” WHO Director-General Tedros Adhanom Ghebreyesus said during a press briefing at the agency’s headquarters in Geneva (6). 3.4% of 212,160,000 in words are two hundred and twelve million, one hundred and sixty thousand deaths globally. We do not know the figures of people with COVID-19 as not everyone is receiving tests, so this is figure is likely inaccurate. At this stage deaths appear to be in the elderly with associated age related diseases (7).
Previous estimated pandemic global death rates
The WHO estimated in a very roundabout way that the Ebola virus resulted in 11 300 deaths and that the expected death toll from a severe influenza pandemic might be 2500 times higher. This is a figure of 28,750,000. The WHO clearly stated that another global pandemic was likely and the world remained woefully unprepared (8). The WHO Global Influenza Surveillance and Response System (GISRS) comprises of 153 institutions in 114 countries (9). The WHO and partners are developing a “Global Influenza Strategy” launched in 2018 (10).
Likelihood of pandemic
Pandemics ignore borders, social class, economic status and age. Globalisation, urbanisation, mass migration and overcrowding accelerate spread. Since 1918 Pandemic Influenza outbreaks have been predictably unpredictable; but always global and needing a global response (11). The Spanish Flu infected one-third of the Earth’s population (500 million people) and is estimated to have killed between 50-100 million (12).
Recent influenza pandemic threats
Avian Flu: 2003 Severe acute respiratory syndrome-related coronavirus (SARSr-CoV), started in China (13).
Swine Flu: 2009 The A (H1N1) Swine Flu started in Mexico, pandemic spread to 214 countries. “The world was lucky” WHO.
Camel Flu: New Global Threat coronavirus Middle East Respiratory Syndrome (MERS) is reported from Saudi Arabia and the Republic of Korea (14).
Coronavirus: 2020 is the latest threat for a global pandemic. This coronavirus is a also known as SARS-CoV-2.
Medical Treatment Options for infleunza
Neuraminidase inhibitors (NA inhibition)
The influenza A virus possesses two surface glycoproteins known as haemagglutinin (HA) and neuraminidase (NA). Balanced HA-NA functions are necessary for efficient influenza virus replication. Inhibiting HA and NA slows down viral replication (15). Three classes of antiviral drugs are available for the prevention and/or treatment of influenza. These drugs are known as neuraminidase inhibitors. Resistance to neuraminidase inhibitors exists and is growing (16). Herbal medicine has been shown to inhibit both NA and HA.
Medical options for seasonal influenza
There is no vaccine for this current coronavirus. Regarding seasonal influenza, the WHO recommends that annual influenza vaccination as the most effective way to prevent influenza. The following discussion aims to help understand the difficulties faced by vaccine manufacturers. An influenza vaccine encourages the body to produce antibodies against virus's haemagglutinin (HA) surface protein. HA is highly mutable, which is why vaccine producers must devise a new formula every year. Influenza vaccine failure can occur when companies incorrectly guess which strains will be in circulation and when circulating strains continue to mutate after the vaccine is made and result in vaccine escape mutants.
Influenza vaccine effectiveness however is a hotly debated with a broad range of estimates. According to Public Health England (PHE) and Eurosurveillance regarding the 2017/18 flu season, the influenza Type B Yamagata lineage was circulating which was contained in the quadrivalent but not in last season’s trivalent 2017/18 vaccine (17, 18). It is known that older people have weaker immune system, meaning their protective immune response is low after vaccination and they don’t produce antibodies against the disease as desired (19).
CDC Eurosurveillance estimates
CDC state flu vaccine effectiveness in reducing risk of flu between 2005 and 2018 ranges from between 10-60% among the overall population (20). Eurosurveillance indicated 2017/18 flu vaccine effectiveness ranged between 25 and 52% (18).
Netherlands prospective observational cohort study
A study in older adults found influenza vaccination effective at reducing laboratory confirmed influenza virus infections but not influenza-like illness (ILI). ILI, also known as acute respiratory infection (ARI) is the reason for hospitalisations. The incidence of ILI was similar between vaccinated and non-vaccinated (21).
A 2014 Cochrane flu vaccine review in 88,000 participants had much lower estimates concluding influenza vaccines “probably have a small protective effect against influenza and ILI”, concluding 71 people needing to be vaccinated to avoid one influenza case (22).
Rice university study
According to Clinical Infectious Disease Journal, the Rice University study predicted the
2018/2019 influenza vaccine to be only 20% effective. The 2019 influenza vaccine is new H3N2 formulation, first time since 2015, and will likely have same reduced effect as the 2016 and 2017 vaccine due to viral mutations related to vaccine production in eggs (23).
Natural anti-viral medicine
Covid -19 is a corona virus like Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and the recently identified Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) (24). Haemagglutinin exists in the structure of the coronavirus and is a target for herbal treatment (25). Neuraminidase inhibitors are the cornerstones of the management of patients hospitalised for suspected MERS-CoV infection and SARS corona virus hence neuraminidase is a potential target for herbal treatment (26).
Constituents in herbs exhibit a diverse array of anti-viral, virostatic, antimicrobial, immune enhancing and anti-influenza activities (27).
COVID 19 and Traditional Herbal Medicines (THMs)
A recent report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) acknowledges the of Chinese government has initiated a series of major emergency research programmes many things but also including traditional Chinese medicines and the WHO are currently looking to determine the effectiveness of Traditional Chinese Medicines (TCM) against COVID-19 (28). Many herbal medicines have demonstrated both in-vitro and in-vivo anti-viral activity.
Anti-viral herbal actions required
Haemagglutinin inhibition (prevent viral replication)
Neuraminidase inhibition (prevent viral replication)
Surface spike protein inhibition (prevent viral entry)
Increasing interferon (boost natural immunity)
Inhibit the cytokine storm (prevent the inflammatory cascade)
Herbal Medicines have demonstrated the follwing actions in in-vitro and in-vivo studies.
Haemagglutinin (HA) inhibition
Influenza haemagglutinin (HA) is a glycoprotein found on the influenza virus surface, along with neuraminidase assists viral replication. (29) The following herbs have been shown to display HA inhibitory effects;
• Catechins isolated from green tea, like EGCG, were found to exhibit mild anti-influenza effect (61) .
• Elderberry (Sambucus nigra) has been traditionally used for treating influenza and colds in western countries. The highly active flavonoids extracted from elderberry inhibit H1N1 infection, comparable to the anti-influenza drug of Oseltamivir. (62) Flavonoids from elderberry extract block viral entry by binding to H1N1 virions. Elderberry inhibits several strains of influenza virus in vitro (30).
• The constituent curcumin in Turmeric (Curcumin longa) targets HA to inhibit virus entry.
• The constituent andrographolide from Andrographis (Andrographis paniculata) displayed inhibitory activity against avian influenza A (H9N2 and H5N1) and human H1N1 influenza A viruses in vitro and in vivo. (64) Andrographolide interferes with HA to prevent the virus from binding to cellular receptors (65).
• The constituent rosmaranic acid from Rosemary (Rosmarinus officinalis) inhibits HA (31).
Neuraminidase (NA) inhibition
Viral neuraminidase is found on influenza virus surfaces and enables viral release from host cells (32).The following herbs have been shown to display NA inhibitory effects;
• The principle active ingredient of the first oral NA inhibitor Oseltamivir is derived from Star anise (Illicium verum) (33).
• Berberine containing herbs such as Barberry (Berberis vulgaris) are antibacterial, antimicrobial, antifungal and antiviral (34). NA inhibition activity of berberines is comparative with Oseltamivir. (35)
• Ganoderma triterpenoids from Reishi (Ganoderma lucidum) display NA inhibition against H5N1 and H1N1 (51).
• Elderberry is also a natural NA inhibitor (36). The compound cyanidin-3sambubiocide, an anthocyanin flavonoid displays potent NA inhibition. (37) The extract displays inhibitory potential on H5N1-type influenza A virus (avian influenza) (36).
Surface spike protein inhibitors
Surface spike proteins are located on the coronavirus surface are involved in mediating the entry of coronavirus into human host cells. Two small molecules, tetra-O-galloyl-beta-D-glucose (TGG) and luteolin have been identified as displaying anti-SARS-CoV activities in wild-type SARS-CoV infection system. TGG is isolated from the traditional Chinese medicine Indian gooseberry (Phyllanthus emblica) (38). More than 200 Chinese medicinal herb extracts were screened for antiviral activities against Severe Acute Respiratory Syndrome-associated coronavirus (SARS-CoV). Four of herbal extracts showed moderate anti-SARS-CoV activity.
The herbal medicines tested were;
• Red spider lily (Lycoris radiate)
• Sweet wormwood (Artemisia annua)
• Large-lipped rustyhood (Pterostylis lingua)
• Japanese evergreen spicebush/ wūyào (Lindera aggregate) (39).
Interferons (IFN) are proteins called cytokines produced by white blood cells.
IFN “interferes" with viral replication to protect cells from virus infections by triggering an increase in natural killer cells, macrophages, phagocytes and other immune cells to eradicate pathogens, not only viruses, but also bacteria, fungus, parasites and tumours (40). IFN up-regulates antigen presentation by increasing the expression of major histocompatibility complex (MHC) antigens which allow T cells to differentiate foreign antigens from self peptides so as to avoid auto-immunity. (40) Fever is mediated by the release of endogenous pyrogens, cytokines such as tumour necrosis factor (TNF), interleukin (IL)-1, IL-6, and IFN into the bloodstream (41).
The following herbs have been shown to increase IFN;
• Elderberry (Sambuccus nigra) fruit extracts enhance IFN-β response (42).
• Astragalus (Astragalus membranaceus) root extract enhances IFN-β response (42). Astragalus polysaccharide enhances immunity and inhibits H9N2 avian influenza virus in vitro and in vivo. (43)
• Echinacea’s (Echinacea angustifolia/Echinacea angustifolia) anti-viral properties are contributed to its action to increase IFN. (44-46) These anti-viral properties are comparable with Oseltamivir (47).
• Curcuma in Turmeric’s (Curcuma longa) immune-stimulatory and anti-inflammatory activities are in part contributed to its ability to increase IFN (63).
Preventing inflammatory cascade (cytokine storm)
The cytokine storm is when immune cells and their activating compounds (cytokines)are overproduced. During influenza infection it is this surge of activated immune cells into the lungs that leads to high mortality rates (48). Suppression of the cytokine release correlates with reduced death rates in clinical diseases such as pandemic influenza where a cytokine storm plays a significant role in high mortality rates (61, 62). The following herbs have been shown to inhibit the inflammatory cascade;
• The immune-modulatory activities of Echinacea (Echinacea purpurea) comprise of stimulation of macrophages phagocytic activity and suppression of the proinflammatory cytokines and chemokine responses of epithelial cells to viruses and bacteria. (49)
• The active constituent andrographolide in Andrographis (Andrographis paniculata) inhibits influenza A virus and reduces inflammatory cytokine expression induced by infection. (50)
• Curcumin (Curcuma longa) a polyphenol in turmeric, inhibits key pro-inflammatory cytokines, interleukin (IL) IL-1, IL-6 and tumour necrosis factor (TNF) TNF-α. (51)
Vitamin D deficiency is described as a European pandemic and deficiency in the Irish well established (52, 53). Vitamin D is known to treat colds. Results in treating flu like symptoms have been described a dramatic (54). Influenza-like illness (ILI) is the reason for hospitalisations in influenza. Decreasing ILI will lower the curve and is the primary objective to reduce the strain on the healthcare system. A 2017 meta-analysis of over 11,000 participants found Vitamin D protected against ILI among all participants and that supplementation was safe. Results were greater in vitamin D deficient participants (55). Investigators found in vitamin D deficient individuals, daily or weekly supplementation cut risk of ILI in half (56). In addition, a meta-analysis concluded that long-term vitamin D supplementation prevents overall mortality (57). The NHS acknowledges that Vitamin D can reduce healthcare associated influenza costs (58).
A Cochrane review looking at Vitamin C for preventing and treating the common cold reported that whilst more research is needed, acknowledged that vitamin C reduced the duration and severity of colds when supplemented regularly (59).
A systematic review and meta-analysis of randomised controlled trials of zinc for the treatment of the common cold found that zinc may shorten the duration of symptoms of the common cold by between two and three days (60). The NHS promote zinc as an immune stimulant and say it can cut length of common cold (61) . A Cochrane study found that zinc inhibits rhinoviral replication and can treat the common cold. The review found that when taken within 24 hours of onset of symptoms, zinc is beneficial in reducing the duration and severity of the common cold in healthy people. People taking zinc are less likely for their cold to persist beyond seven days of treatment. Zinc supplementation for at least five months reduces incidence, school absenteeism and prescription of antibiotics for children with the common cold (62).
Acute respiratory infection (ARI)
Influenza-like illness (ILI)
Major histocompatibility complex (MHC)
Tumour necrosis factor (TNF)
World Health Organisation WHO
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