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By
the end of April 2013, the World Health Organization (WHO) had reported 24
deaths and more than 125 laboratory-confirmed human infections associated with
avian influenza A(H7N9), which first made headlines in March as the latest
animal-borne flu outbreak to hit China.1 A widely quoted WHO
official called H7N9 “one of the most lethal viruses that we have seen so far,”2
and the death rate — roughly 20% of all
cases — is significantly greater than 2003’s
highly infectious SARS (Severe Acute Respiratory Syndrome) pandemic, which
infected more than 8,000 and killed 774 individuals,3 as well as the
2009 H1N1 “swine flu” pandemic, which resulted in approximately 275,000
hospitalizations and more than 12,000 deaths worldwide, although reported
figures vary.4
So
far, infections and deaths have been focused around southern and eastern
provinces of China, including Fujian, Jiangsu, Jiangxi, Anhui, and Zhejian — which
surround the municipality of Shanghai. Thirteen deaths from the virus, more
than half of the total, have occurred in Shanghai.5 However,
officials from Hunan Province, more than 600 miles away from Shanghai, recently
reported its first H7N9 infection, and the first death in Taiwan, an island nation
off the southeastern coast of China that is home to more than 23 million people,
was reported in the last week of April.2,10
According
to the US Centers for Disease Control and Prevention (CDC), most infections
have occurred in individuals who have come into close contact with infected
poultry. “Infected birds can shed a
lot of flu virus, for example, in their droppings or their mucus,” the CDC
states on its website. “If someone touches an infected bird or an environment
contaminated with virus and then touches their eyes, nose or mouth, they may be
infected with bird flu virus.”6
Demand Increases,
Science Lacks for Ban Lan Gen Herb
In March and
April, news agencies reported shortages of certain traditional Chinese herbal
medicines quickly sought by residents in hopes of fortifying themselves against
the lethal virus. One such herbal ingredient, ban lan gen, was in particularly high demand after April 3rd, when the local
government of Jiangsu Province published an online report
recommending officials “explore and develop the role of Chinese medicine” in
treating the new strain of bird flu. According to an article by The Washington Post, the report included
a list of herbs believed to be helpful in treating infected patients, such as Asian
ginseng (Panax ginseng), licorice (Glycyrrhiza glabra), and ban lan gen.7
Although
the online list included herbs supposedly helpful in treating bird flu infection, ban
lan gen was suggested by province officials as an option for preventing infection as well. Traditional
Chinese Medicine (TCM) clinics sold out of ban
lan gen virtually overnight, and orders on Taoboa.com, the Chinese
equivalent of eBay, skyrocketed. Officials in nearby provinces made similar
recommendations, although many have since backed off their announcements.7
ABC Advisory Board member Subhuti Dharmananda,
PhD, who runs the Institute for Traditional Medicine and Preventative Health
Care, Inc. (ITM) in Portland, Oregon, explained that ban lan gen is used traditionally in TCM to clear heat and
eliminate toxins.
“Ban lan gen means the root (gen) of the herb, ban lan, which can be obtained from Isatis tinctoria [‘dyer’s woad’], I. indigotica [‘isatis’], and Baphicacanthus
cusia [‘assam indigo’],” he explained (email, April 22, 2013). “It is
characteristically used, in modern terms, for various kinds of infections. Laboratory
studies indicate action against several bacteria and viruses.”
According to the 2001 book Chinese
Medical Herbology and Pharmacology (Art of Medicine Press) — co-written by
John Chen, PhD, PharmD, OMD, LAc — ban
lan gen “can be used to treat encephalitis B, hepatitis, chickenpox,
epidemic parotitis, and viral dermatitis.” Dr. Chen lists its pharmacological
effects as being antibiotic, immunostimulant, and antiplatelet, all of which
are based on in vitro or animal
studies.8
In his book, Dr. Chen writes that in one clinical
study of 46 patients with upper respiratory tract infections, 40 patients experienced
complete recovery with ban lan gen,
with six others reporting moderate improvements. 8 No clinical
trials of ban lan gen for avian
influenza have been conducted at this time.
On
the ITM website, Dr. Dharmananda wrote extensively about the use of traditional
Chinese herbs used during the 2003 SARS pandemic. Ban lan gen was one such herb, but there remains a dearth of
research and science to support its use against deadly, seasonal viruses such
as avian influenza.
“The reason ban
lan gen was used for SARS is because ban
lan gen is readily available, and has a good reputation as a having a broad
spectrum action against infections,” he said. “It is not possible to run
clinical trials on a short term epidemic, such as SARS.”
A 2013 Cochrane Collaboration Review of Chinese
medicinal herbs for influenza found a limited number of high-quality,
randomized, controlled clinical trials. Of the 18 trials, the authors included
in their analyses, “only three indicated that compared with antiviral drugs,
Chinese medicinal herbs showed a superior effect in preventing influenza and
alleviating influenza symptoms.” These three trials studied the effects of
various TCM herbal combination formulations such as Ganmao Jiaonang, Lianhua Qingwen,
and Antiwei. Ban lan gen was not mentioned as an ingredient in these
formulations used in the trials.
The Cochrane Review authors concluded, however, that the “current evidence is
too weak to draw a conclusion which supports or rejects the use of any Chinese
medicinal herbs for preventing or treating uncomplicated influenza.”9
Treatment Recommendations
Importantly,
H7N9 is not believed to be able to be passed from human to human, as was the
case for SARS. However, recent reports of the virus in the four-year-old son of
Shendong Province’s first H7N9 patient have brought this assumption into
question.10 Further investigations are needed to confirm possible
human-to-human transmission.
Currently,
the Chinese Center for Disease Control and Prevention (CCDCP) recommends that
H7N9 patients should be isolated with “respiratory and
enteric precautions,”
and be treated for symptoms and started on antiviral drug regimens, preferably
within 48 hours of symptom onset. The three antiviral drugs recommended include
Oseltamivir
(commonly known as Tamiflu® in the United States, which was
originally modeled after a compound in Chinese star anise [Illicium verum]11), Zanamivir (Relenza® in the United States), and Peramivir.12
The
CCDCP also includes a section on “Chinese
traditional medicine treatment,” which mentions two treatments used to “clear heat and poison from the body, diffuse the lungs to relieve cough,”
or to “detoxif[y] to relieve the burden of lung, maintain and support body
functions.” Numerous herbal combinations are listed; however, ban lan gen is not mentioned as a
preferred treatment. Additionally, the recommendation clarifies that “the above
mentioned Chinese traditional medical decoctions, synthetic medicines, and
injections should not be used to prevent disease.”12
The
United States Centers for Disease Control and Prevention (CDC) recommends that “Because of the potential severity
of illness associated with H7N9 virus infection, it is recommended that all confirmed
cases, probable cases, and H7N9 cases under investigation … receive antiviral treatment with
a neuraminidase inhibitor as early as possible.”13
Neuraminidase inhibitors are a class of antiviral drugs that include the Food
and Drug Administration (FDA)-approved Tamiflu and Relenza. According to FDA’s
website, “Older drugs, amantadine and rimantadine, are approved for treatment
and prevention of influenza A. But many strains of influenza, including the
2009 H1N1 influenza, are now resistant to these two drugs. CDC has not
recommended the use of these two drugs for recently circulating influenza
viruses.”14
There
is currently no vaccination available for H7N9, although the CDC is working to develop one, with media reports saying it could be available as
early as August of this year, in case the outbreak spreads.15
Despite the lack of evidence for herbs such as ban lan gen for the treatment or
prevention of avian influenzas such as H7N9, many Chinese residents in affected
areas are turning to such traditional Chinese herbs.
“Herbs used for prevention are not like vaccinations,” said Dr. Dharmananda. He
explained that herbs used for prevention, which may or may not actually work,
might be employed to bolster general immune responses, whereas vaccines bolster
specific immune responses. Herbs also might be used to produce bodily harmony (e.g., counteract negative impacts of the
seasonal conditions on health), or might simply treat the infection at the time
it is acquired, which is a potentially easier task than treating the infection after
the organism has fully manifested.
“Their basis for such faith in the herbs is experience, not science,” continued
Dr. Dharmananda. “They either have their own personal experience or they
have experience relayed to them from parents, grandparents, friends, and
others, who may report good results from prior use of Chinese herbs. The fact
is that when there is not a clear solution from modern medicine (as was the
case for SARS), people turn to what they can, and that is herbs.”
—Tyler Smith
References 1. Human infection with avian influenza A(H7N9) virus –
update. World Health Organization website. Available here. Accessed April 29, 2013.2.
Shadbolt P. WHO: H7N9 virus
'one of the most lethal so far'. CNN. Available here. Accessed April 26, 2013.3. SARS basic fact sheet. Centers for Disease
Control and Prevention website. Available here. Accessed April 26, 2013. 4. Summary of WHO Technical Consultation: H1N1pdm
Mortality Estimates. World Health Organization website. Available here. Accessed April 26, 2013.5.
Flannery R. Shanghai reports 13th H7N9 bird flu
death, tops among Chinese cities. Forbes. Available here. Accessed April 29, 2013.6.
Wan W. In China, bird flu brings panic
buying of herbal remedy called ban lan gen. Washington
Post. Available here. Accessed April 28, 2013.7. Chen JK, Chen TT. Ban Lan Gen (Radis
Isatidis). Chinese Medical Herbology and
Pharmacology. City of Industry, CA: Art of Medicine Press; 2001:210-211. 8. Jiang L, Deng L, Wu T. Chinese medicinal herbs
for influenza (review). The Cochrane Collaboration website. Available here. Accessed April 24, 2013. 9. Schnirring L. H7N9 found in China's Hunan province
as outbreak grows to 126. Center for Infectious Disease Research
& Policy website. Available here.
Accessed April 29, 2013.
10. H7N9: Frequently asked questions. Centers for Disease Control and
Prevention website. Available here. Accessed May 2, 2013.11. Awang DVC, Blumenthal M. Tamiflu and star
anise: Securing adequate supplies for the oral antiviral for avian flu
treatment. HerbalGram. 2006;70:58-60.
Available here. Accessed May 1,
2013. 12. Diagnostic and treatment protocol for human
infections with avian influenza A (H7N9). Chinese Center for Disease
Control and Prevention website. Available here. Accessed April 29, 2013. 13. Interim Guidance on the Use of Antiviral Agents for
Treatment of Human Infections with Avian Influenza A (H7N9). Centers for
Disease Control and Prevention website. Available here. Accessed April 29, 2013.14. Influenza (Flu) Antiviral Drugs and Related
Information. Food and Drug Administration website. Available here. Accessed April 24, 2013.15.
H7N9
vaccines will be available in August: pharmaceutical firm. Focus Taiwan News
Channel website. Available here. Accessed April 24,
2013.
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