There are growing concerns about a possible pandemic of virulent influenza, possibly from mutations of a "bird flu" that has cropped up in several countries, including Thailand, Vietnam, Turkey, and Romania. News reports have sometimes been highly alarming, which is only partly justified.

Thus far, the flu has only been transmitted from bird to bird or from bird to human, and the number of human cases has been small, since it is necessary to have some contact with infected birds. Even if the bird flu were to show up locally, the chances of contracting the disease from the birds remains very low. Currently, this flu virus has a greater than 50% death rate associated with it, which is one of the reasons for the expressed fears about it.

The concern is that a mutation will arise that allows human to human transmission; in other words, the flu could be a sneeze away. 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. Those deaths included people who were relatively healthy; the death rate from the Spanish flu was only about 5%. We do not know how virulent the avian flu virus will be if it becomes a human borne disease (it may be considerably milder than it is now), but there are worries that there an international disaster of proportions difficult to imagine is looming.

Such an outbreak will not likely occur this year (2005-2006); the flu season has already begun and will be over in a few months. But, there is the possibility that it will come as early as next year. Extensive efforts already underway to control this flu (e.g., destroying chicken populations that are infected, as well as eliminating potentially contaminated fowl and wild animals in the immediate vicinity) might be successful. In that case, the feared epidemic from it would not occur; also, there is significant work towards developing a vaccine. With modern genetics and pharmaceutical science, this is not difficult to accomplish now, but such 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 that occurred last season, there are great concerns about the supplies of flu vaccine that would have to be developed and efforts are underway to enhance production capabilities.

An analysis presented this year indicated that flu vaccines may have a low efficacy rate, 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). The low efficacy may be related to new flu strains arising (the vaccines are specific for certain strains, which must be determined before the flu season begins in order to make the vaccine in time). There are also flu drugs now coming into use, such as the inhalant Relenza (zanamivir), which was approved by the FDA in 1999, or the pill/syrup version called Tamiflu. Several countries are stockpiling supplies just in case. 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 reasonably high 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. During the past year, serious natural disasters (including the Indonesian Tsunami, the Gulf Hurricanes and their resultant flooding, the earthquake in Pakistan) and extensive war tragedies (including those in Afghanistan, Iraq, and Sudan) may be contributing conditions favorable to a more serious flu season. These conditions are related to mass movements of populations, development of unsanitary conditions, and disruptions in the normal supplies of foods and medicines. Although natural disasters and war have been a constant companion of mankind, as the human population grows, the effect of these problems on disease transmission can increase.

A 2004 U.S. planning document 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-December, with some early cases appearing in October and some lingering spread of the disease in January (in 2003, the peak occurred during the week of December 13-20), but the 2004-2005 season was unusual: it started slowly and the peak did not occur until February. Outside of these times (late Fall, early Winter), there are relatively few cases of influenza, but there are some other diseases that present symptoms similar to influenza and may not be distinguished from it without medical testing.

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

CHINESE HERBS AND INFLUENZA

Unlike the vaccines, Chinese herb therapies for influenza are not specific for the viral strain. Instead, they may have general actions such as to help boost the immune response to help eliminate the virus faster. At high enough dosage they may have some direct (but general) inhibitory effects on viral reproduction, and they may simply ameliorate some of the symptoms, thus making a serious infection seem mild. There is not one herb or formulation that is known to be a reliable treatment for flu; rather, 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. 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. Prescription of herbs for these purposes 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.

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. It is worthwhile to review the therapeutic approach described by the Chinese and some of the readily available remedies (ITM formulary items will be described here; others are easily obtained).

A REGIMEN FOR SEVERE INFLUENZA

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: 5-6 tablets each time, three times daily
• Myrolea-B: 1 tablet each time, three times daily
• Calmagnium: 1 tablet each time, three times daily

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. 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.

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 three days of symptoms for influenza. 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 a formula aimed at relief of symptoms, such as for nasal congestion, sore throat, or bronchial infection with cough.

For those who are worried about high susceptibility to influenza (due to past experience of frequent infection by cold and flu 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 10 weeks) in an effort to avoid developing a symptomatic infection after exposure. Jade Screen Formula (see article: Yupingfeng San about the traditional version made of three herbs, astragalus, siler, and atractylodes) and its variants are the most widely studied prescriptions for prevention of upper respiratory tract infections. Astragalus 10+ (see detailed analysis of formula: Astragalus 10+) is 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. 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 to it occurs, perhaps being effective at dosages lower than those described here.

It is important to note that high doses of immune enhancing formulas may not be suitable for use in treating the flu during its primary active phase. The harmful effects of the flu at that time may 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. Usually, information about pathology of the virus that dominates a flu season will be available and can be checked to determine whether this immunological concern requires attention. 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.

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

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%

Myrolea-B
jinyinhua Lonicera 25%
lianqiao Forsythia 25%
Olive leaf 25%
huangqin Scute 20%
hezi Terminalia 10%

Calmagnium
Four tablets provide:
(percentage of U.S. RDA in parentheses)

Minerals:
(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

Vitamins:
(100) Vitamin A 5,000 IU
ß-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

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%

Isatis 6
daqingye Isatis 25%
huzhang Hu-chang 15%
xiakucao Prunella 15%
baihuasheshecao Oldenlandia 15%
chuanxinlian Andrographis 15%
jinyinhua Lonicera 15%

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