• George Wang, MD, PhD

Coronavirus and upper respiratory infections: holistic considerations



Coronaviruses are among the many different viruses that can cause the common cold, contributing to about 10 to 15% of cases. Other viruses that cause the common cold include rhinoviruses, influenza virus, respiratory syncytial virus, and parainfluenza virus.


When a coronavirus is discovered that does not match any other previously known virus, it is called a novel coronavirus. The cause of the outbreak of a cluster of pneumonia cases in Wuhan, a city in the Hubei province of China, at the end of 2019 has been identified to be a novel coronavirus (1). This virus, linked to a seafood wholesale market, has been referred to in the media as the “mystery virus.”


Coronavirus infections typically result in fever and upper respiratory tract symptoms such as nasal congestion, runny nose, and cough. In more severe cases, infections can result in pneumonia and even fatality. What is different about the recent novel coronavirus is that it tends to be associated with more severe diseases, including pneumonia and critical illness such as respiratory failure (2). Most of the fatalities have occurred in people with underlying medical comorbidities.

While the understanding of this novel coronavirus continues to evolve rapidly, both the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) have issued interim guidance on diagnosis and clinical management (3, 4).



Diagnosis

Because there is no effective treatment for coronavirus infections, typically there is no clinical utility in establishing the diagnosis of coronavirus infection in cases of the common cold. In the case of the 2019 novel coronavirus, diagnostic testing can only be done at the CDC at this time.



Infection control

Coronaviruses are spread from animals to people, and from people to people, through direct contact with infected secretions or large aerosol droplets. As with rhinovirus infections, the most common cause of cold symptoms, prevention consists of handwashing and carefully disposing of infected nasal secretions.


The CDC has published an interim guidance on how to prevent the spread of the 2019 novel coronavirus from an infected person to others (https://www.cdc.gov/coronavirus/2019-ncov/guidance-prevent-spread.html)


The WHO has also published recommendations on how to reduce your risk of infection by the novel coronavirus (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public).


Taken from WHO’s recommendations, here are simple and important steps to reduce your risk of coronavirus infection:

· Wash hands with soap and water or clean with alcohol-based hand sanitizer

· Cover nose and mouth when coughing with tissue or flexed elbow

· Avoid close contact with anyone with cold or flu-like symptoms

· Thoroughly cook meat and eggs, if these are a part of your diet (or preferably, choose to eat plants over meat and eggs)

· Avoid unprotected contact with live wild or farm animals


If you suspect that you have touched an infected person or have transferred potentially infected secretions, fluids, or droplets onto your hands, make sure that you thoroughly wash your hands with soap and water before touching your face. Coronavirus, and respiratory viruses in general, most often gain entry into our bodies through the mucosal surfaces of our eyes, nose, and mouth.


Treatment and prevention

No antiviral drugs have been established to be effective against coronaviruses. There is currently no recommended treatment for coronavirus infections, including the novel coronavirus (the “mystery virus”) other than supportive care as needed.


As with all viral infections, antibiotics are completely ineffective in eradicating coronaviruses and other upper respiratory viral infections. However, antibiotics may sometimes be prescribed by clinicians if there are concomitant bacterial infections or superimposed bacterial infections (“bacterial superinfections”).


It is important to understand that whether a person ultimately becomes sick after exposure to an upper respiratory pathogen is determined by both the host (the exposed person) and microbial factors. Host factors include 1) the competence of a person’s immune system, 2) the functional status of specialized ciliary epithelial cells (cells lining the airways that clear out pathogens through the beating of their hairs, or cilia), 3) the hydration status of the periciliary fluid layer (the layer below the mucus layer), which affects optimal clearance function of the mucus and, in turn, the ability to prevent biofilm growth and subsequent inflammation, and 4) the microbiome (the population of beneficial and harmful microbes that live in and on our body). Beneficial, or commensal, microbes help us by outcompeting pathogens that may try to lay claim to the same living space in the airways (5).


In integrative medicine and functional medicine, the terms “improving the terrain” and “treating the terrain” have been used to refer to changing the inner environment of the body such that it will be much harder for pathogens to thrive. In other words, if we strengthen the host factors, if we optimize our body’s innate ability to fend off foreign invaders and heal itself, then we will have tipped the scale in our efforts to prevent and treat upper respiratory infections, or most any infections for that matter.


Exercise is associated with both reduced severity and duration of upper respiratory infections (6). Many lines of evidence suggest that frequent exercise improves immune competency (7). Therefore, engaging in regular physical activity and exercise is an important part of a holistic approach to preventing upper respiratory infections.


Following a healthful food plan that includes primarily whole foods and diverse plants that provide abundant fibers and phytonutrients can significantly influence the gut microbiome and affect the immune response. (More in other blogs.) In my personal experience, eating organic foods rather than conventionally-produced foods can also reduce the frequency of colds. Animal studies show that feeding organic foods to animals improved their immune system. Human epidemiological studies show an association between eating organic foods and lower risks of allergies (in other words, the immune system was affected), but results from intervention studies are ambiguous (8).


Several botanicals, or herbal medicines, have been used in the treatment of viral upper respiratory infections, including echinacea, astragalus, andrographis, elderberry, ginger, goldenseal, and pelargonium (umckaloabo). However, clinical trials for these botanicals often have conflicting results, with some trials showing positive effects and other showing negative (no beneficial) effects. Similarly, while there is more evidence for the use of vitamin C and zinc in upper respiratory infections than any single conventional therapy, clinical trials for these two micronutrients have shown mixed (positive and negative) results (9).


It is important to understand, though, that mixed clinical trial results do not necessarily preclude true clinical benefit from the use of these agents. Rather, in the art of the practice of medicine, tailoring treatments for specific individuals, based on their medical history, body constitution and biochemical individuality, and their preferences and belief systems is an important component in the practice of “evidence-based medicine.” Such specific tailoring and finetuning of treatments are often difficult to carry out in large clinical trials.


Keep in mind that supplements and herbal medicines may have potential side effects, and may have potential drug-to-drug interactions with conventional prescription and over-the-counter medications (such as increasing or decreasing the latter’s metabolism by the body and, as a result, their clinical effects, with sometimes dire consequences). Consult a physician or healthcare provider who is knowledgeable about dietary supplements and botanicals before starting them.



Mind-body medicine

Stress, both acute and chronic, increases the risk for upper respiratory infections (10, 11). Stress does so by weakening the airway immune response as well as by directly affecting microbial growth through hormonal outputs (5). Stress management, therefore, can play a role in treating and preventing upper respiratory infections. In fact, in a randomized controlled trial, an 8-week training in mindfulness-based stress reduction (MBSR) was associated with lower severity of illness from acute respiratory infections (12). There was a suggested trend toward lower incidence and duration of illness, but these results did not reach statistical significance. A similar trial that enrolled a wider age range of participants also suggested reduced incidence of acute respiratory infection in people who practice meditation for 8 weeks, but the results did not reach the pre-specified level of statistical significance (13).


Interestingly, patients with the common cold who perceived greater empathy from their physicians had shorter cold duration and lower cold severity, as well as a larger increase in the levels of a player in the immune response (the cytokine, interleukin-8) (14).


In summary, a holistic medicine approach to the prevention and treatment of upper respiratory infections considers fundamental infection control strategies, optimization of immune competence through lifestyle changes (diet, exercise, and stress management), and judicious, tailored uses of botanicals and dietary supplements under guidance.


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Information on the novel coronavirus continues to change frequently. The information discussed here is only current as of the date of the blog. Check the WHO and CDC websites for updated information.


References

1. Zhu, N., et al. 2020. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med, 382, 727-733.


2. World Health Organization. January 22, 2020. Novel coronavirus situation report - 2. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200122-sitrep-2-2019-ncov.pdf (Accessed on January 25, 2020).


3. World Health Organization. https://www.who.int/health-topics/coronavirus(Accessed on January 24, 2020)


4. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-nCoV/clinical-criteria.html(Accessed on January 24, 2020)


5. Stover, C. 2016. Mechanisms of stress-mediated modulation of upper and lower respiratory tract infections. Adv Exp Med Biol, 874, 215-23.


6. Nieman, D., et al. Upper respiratory tract infection is reduced in physically fit and active adults. Br J Sports Med, 45, 987-92.


7. Campbell, J. & Turner, J. 2018. Debunking the Myth of Exercise-Induced Immune Suppression: Redefining the Impact of Exercise on Immunological Health Across the Lifespan. Front Immunol, 9, 648.


8. Huber, M., et al. 2011. Organic food and impact on human health: Assessing the status quo and prospects of research. Njas-Wageningen Journal of Life Sciences, 58, 103-109.


9. Barrett, B. 2017. Viral upper respiratory infection. In: Rakel, D. (ed.) Integrative Medicine. Fourth ed. Philadelphia: Elsevier.


10. Graham, N, et al. 1986. Stress and acute respiratory infection. Am J Epidemiol, 124, 389-401.


12. Cohen, S., et al. 1991. Psychological stress and susceptibility to the common cold. N Engl J Med, 325, 606-12.


12. Barrett, B., et al. 2012. Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial. Ann Fam Med, 10, 337-46.


13. Barrett, B., et al. 2018. Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial. PLoS One, 13, e0197778.


14. Rakel, D., et al. 2009. Practitioner empathy and the duration of the common cold. Fam Med, 41, 494-501.


#integrativemedicine #functionalmedicine #coronavirus #covid-19 #mindbodyconnection #exercise #stressmanagement #MBSR #holisticmedicine

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