Human Avian/ Bird Flu and Chinese medicine

Human Avian/Bird Flu and Chinese medicine

Translation and interpretation of section 5.4.1 of <人禽流感诊疗方案(2005版修订版)> (Ren Qin Liu Gan Zhen Liao Fang An (2005 Ban Xiu Ding Ban); Human Bird/Avian Flu Treatment Policy (2005 Revision version)), issued on November 23rd, 2005, by the Ministry of Health, People’s Republic of China.

The policy is the third revision (and the latest up to June 14, 2008) since the first publication in 2004. This new revision was compiled by 25 specialists in the departments of epidemiology, pulmonology, paediatrics, emergency, medical imaging, medical examination, virology, physical examinations & clinical skills.

Below is translation of section 5.4.1 of the policy which details Chinese herbal treatments of Bird Flu in accordance to TCM syndromes. Four syndromes are listed. Modification tips are given for reference. Comments by John Lew explain how the herbs play different cohesive roles in treating different syndromes.

5.4.1 Chinese herbal treatments of Avian/Bird Flu in accordance to TCM syndromes:

5.4.1.1)
Syndrome: External toxins invading Lungs
Symptoms: Fever, aversion to cold, sore throat, headache, muscle and joint pain, coughing, little phlegm, tongue with white coat, rapid and slippery pulse.
Mechanism: Toxins invading Lungs’ protective layer, Lungs losing the ability to maintain upward & downward qi passage.
Therapeutic principles: Clear away heat and toxins, activate the flow of qi, and penetrate external pathogens.

Basic formula (Ingredients) & reference dosage:
No. 1) 柴胡10g (Chai Hu, Chaihu, Bupleurum root, Radix Bupleuri);
No. 2) 黄芩12g (Huang Qin, Huangqin, Scutellaria root, Radix Scutellariae);
No. 3) 炙麻黄6g (Zhi Ma Huang, Honey-baked Mahuang, Honey-baked ephedra, Herba Ephedrae Praeparata);
No. 4) 炒杏仁10g (Chao Xing Ren, Fried Xingren, Fried bitter apricot kernel, Semen Armeniacae Amarum);
No. 5) 银花10g (Yin Hua, Yinhua, Honeysuckle flower, Flos Lonicerae);
No. 6) 连翘15g (Lian Qiao, Lianqiao, Forsythia fruit, Fructus Forsythiae);
No. 7) 牛蒡子15g (Niu Bang Zi, Niubangzi, Arctium fruit, Fructus Arctii);
No. 8) 羌活10g (Qiang Huo, Qianghuo, Notopterygium root, Rhizoma seu Radix Notopterygii);
No. 9) 白茅根15g (Bai Mao Gen, Baimaogen, Lalang grass rhizome, Rhizoma Imperatae);
No. 10) 芦根15g (Lu Gen, Lugen, Reed rhizome, Rhizoma Phragmitis);
No. 11) 生甘草6g (Unprepared Gan Cao, Sheng Gancao, Licorice root, Radix Glycyrrhizae)

Modifications: For severe cough, add 炙枇杷叶(Zhi Pi Pa Ye, Honey-prepared Pipaye, Loquat leaf, Folium Eriobotryae Praeparata), 浙贝母(Zhe Bei Mu, Zhebeimu, Thunberg Fritillary Bulb, Bulbus Fritillariae Thunbergii). For Nausea and vomiting, add 竹茹(Zhu Ru, Zhuru, Bamboo shavings, Caulis Bambusae in Taeniam), 苏叶(Su Ye, Suye, Perilla leaf, Folium Perillae).

John’s comments:
1) This formula combines that of 银翘散(Yin Qiao San, a powder formula for the treatment of superficial syndrome of wind-heat, consists of 10 herbs) and 麻杏甘石汤(Ma Xing Gan Shi Tang, a decoction formula for the treatment of cough and dyspnea due to wind-heat, consists of 4 herbs) with modifications. Chai Hu dispels pathogenic heat in the half exterior. Huang Qin clears out stagnated heat in the half interior. The combined use of the two herbs removes pathogenic factors from Shao Yang channels. Ma Huang facilitates the flow of the Lung-qi to relieve asthma, and its pungent flavor is good at dispelling exogenous factors. When used in honey-baked form, the effect in relieving asthma and cough is stronger. Xing Ren, with bitter taste and warm property, helps to move the Lung-qi to the lower part of the body. Yin Hua and Lian Qiao, pungent in flavor and cool in property, are used to relieve the exterior syndrome and clear away pathogenic heat and toxic materials. Niu Bang Zi and Gan Cao are used to relieve sore throat and cough by clearing away toxins and removing phlegm and, furthermore, the pungent and cool property of Niu Bang Zi is good for dispelling exterior heat. Qiang Huo, pungent in flavor and warm property, is used to expel exterior wind, remove dampness and relieve pain. Bai Mao Gen, being cold and sweet, helps to cleanse heat in the Lungs and Stomach. Lu Gen, sweet in flavor and mild cool in property, is used to remove pathogenic heat and promote the production of body fluid and relieve thirst and restlessness, working in tandem with Bai Mao Gen.

2) The formula seems more inclined in catering for wind-heat syndrome. The use of Ma Huang, Qiang Huo, even though warm and pungent, helps in arresting asthmatic symptoms and removing dampness. Tongue impression for wind-heat is usually thin yellowish fur, in contrary to what’s stated above. Anyway, all other factors are to be taken into account.

5.4.1.2)
Syndrome: Toxins invading Lungs and Stomach
Symptoms: Fever, or aversion to cold, headache, muscle and joint pain, nausea, vomiting, diarrhea, lower abdomen pain, tongue with whitish greasy fur coupled with floating and slippery pulse.
Mechanism: Toxins invading Lungs and Stomach, dampness accumulated at Stomach and Intestines, causing disruption of downward movement.
Therapeutic principles: Clear away heat and toxins, remove dampness and regulate Stomach.

Basic formula (Ingredients) & reference dosage:
No. 1) 葛根20g (Ge Gen, Gegen, Pueraria Root, Radix Puerariae);
No. 2) 黄芩12g (Huang Qin, Huangqin, Scutellaria root, Radix Scutellariae);
No. 3) 黄连6g (Huang Lian, Huanglian, Coptis Root, Rhizoma Coptidis);
No. 4) 鱼腥草30g (Yu Xing Cao, Yuxingcao, Houttuynia herb, Herba Houttuyniae Heartleaf);
No. 5) 苍术10g (Cang Zhu, Cangzhu, Atractylodes, Rhizoma Atractylodis);
No. 6) 藿香10g (Huo Xiang, Huoxiang, Agastache, Herba Agastachis);
No. 7) 姜半夏10g (Jiang Ban Xia, Ginger-prepared Banxia, Ginger-prepared pinellia tuber, Rhizoma Pinelliae Praeparata);
No. 8) 厚朴6g (Hou Pu, Houpu, Macrostem onion, Bulbus Allii Macrostemi);
No. 9) 连翘15g (Lian Qiao, Lianqiao, Forsythia fruit, Fructus Forsythiae);
No. 10) 白芷10g (Bai Zhi, Baizhi, Dahurian angelica root, Radix Angelicae Dahuricae);
No. 11) 白茅根15g (Bai Mao Gen, Baimaogen, Lalang grass rhizome, Rhizoma Imperatae)

Modifications: For severe stomachache, add 炒白芍(Fried Bai Shao, Chao Baoshao, White peony root, Radix Paeoniae Alba)、炙甘草(Honey-baked Gan Cao, Zhi Gancao, Honey-baked licorice root, Radix Glycyrrhizae Praeparata). For severe cough, add 炒杏仁(Chao Xing Ren, Fried Xingren, Fried bitter apricot kernel, Semen Armeniacae Amarum), 蝉蜕(Chan Tui, Chantui, Cicada slough, Periostracum Cicadae).

John’s comments:
1) This formula combines that of 葛根黄芩黄连汤(Ge Gen Huang Qin Guang Lian Tang, a decoction formula for the syndrome of toxins invading both Lungs and Stomach, consists of 4 herbs) and 平胃散(Ping Wei San, a powder formula for the treatment of stagnancy of dampness in the Stomach and Spleen, consists of 4 herbs) with modifications. Ge Gen, sweet and pungent in flavor and cool in property, dispels pathogenic factors from the superficial muscles to reduce fever and invigorates Spleen-Yang to stop diarrhea. Huang Lian, bitter in flavor, cold in property, acting on the Heart, Stomach, Liver and Large Intestine channels, purges pathogenic fire in the Heart and Stomach. Huang Qin acts to clear away heat in the Lungs and purge fire in the upper body. Cang Zhu dispels dampness to promote the function of the Spleen. Hou Pu promotes qi circulation and eliminates dampness to relieve distension and fullness in the abdomen. Huo Xiang, with a pungent and aromatic smell, not only dispels wind but also expels the turbid pathogen and regulates the Stomach to arrest vomiting; meanwhile it can send up the lucid qi and send down the turbid, clear away summer-heat and filthy pathogens. Ban Xia dries dampness and regulates Stomach, lowers the adverse flow of qi to arrest vomiting. Bai Zhi expels wind to relieve pain and removes dampness. Yu Xing Cao, pungent in flavor and mild cold in property, clears heat and toxins from the Lungs. It also subdues swelling and promotes pus discharge. Lian Qiao, pungent in flavor and cool in property, is used to relieve the exterior syndrome and clear away pathogenic heat and toxic materials. Bai Mao Gen, being cold and sweet, helps to cleanse heat in the Lungs and Stomach.

2) Comparing to formula 5.4.1.1, this formula of 5.4.1.2 tailors the direction toward getting rid of dampness around the middle part of the body, namely Stomach and Spleen, by regulating qi movement and drying dampness.

5.4.1.3)
Syndrome: External toxins clouding Lungs
Symptoms: High fever, cough with fewer phlegm, chest numbness, asthmatic short breath, or palpitation, restlessness, agitation, even delirium, coma, deep purplish lips, dim-red tongue with greasy gray or yellow fur and sunken fine and rapid pulse.
Mechanism: Severe case of toxins invading and clouding Lungs, causing disruption of upward & downward qi passage, thus the high fever and cough; phlegm accumulation and stagnation of Lungs, thus dim purplish lips and asthmatic short breath.
Therapeutic principles: Clear away heat and purge Lungs, remove toxins and resolve phlegm.

Basic formula (Ingredients) & reference dosage:
No. 1) 炙麻黄9g (Zhi Ma Huang, Honey-baked Mahuang, Honey-baked ephedra, Herba Ephedrae Praeparata);
No. 2) 生石膏30g先下(Xian Xia; Boiled first) (Sheng Shi Gao, Unprepared Shigao, Gypsum, Cypsum Fibrosum);
No. 3) 炒杏仁10g (Chao Xing Ren, Fried Xingren, Fried bitter apricot kernel, Semen Armeniacae Amarum);
No. 4) 黄芩10g (Huang Qin, Huangqin, Scutellaria root, Radix Scutellariae);
No. 5) 知母10g (Zhi Mu, Zhimu, Wind-weed rhizome, Rhizoma Anemarrhenae);
No. 6) 浙贝母10g (Zhe Bei Mu, Zhebeimu, Thunberg Fritillary Bulb, Bulbus Fritillariae Thunbergii);
No. 7) 葶苈子15g (Ting Li Zi, Tinglizi, Lepidium seed, Semen Lepidii seu Descurainiae);
No. 8) 桑白皮15g (Sang Bai Pi, Sangbaipi, White mulberry root-bark, Cortex Mori);
No. 9) 蒲公英15g (Pu Gong Ying, Pugongying, Mongolian dandelion herb, Herba Taraxaci);
No. 10) 草河车10g (Cao He Che, Caoheche, [重楼, Chong Lou, Chonglou, Chinese paris rhizome, Rhizoma Paridis Chinensis]);
No. 11) 赤芍10g (Chi Shao, Chishao, Red Peony Root, Radix Paeoniae Rubra);
No. 12) 丹皮10g (Dan Pi, Danpi, Mountan Bark, Cortex Moutan Radicis)

Modifications: For high fever, unresponsiveness, or even delirium, add 安宫牛黄丸(Angong Niuhuang Wan / AnGong NiuHuang Pill, a OTC pill for treatment of high fever, delirium, coma due to phlegm-heat in the Heart or pathogenic heat in pericardium, consists of roughly 12 herbs (depending on manufacturers)); with a choice of using 清开灵注射液(QingKaiLing Injection), 痰热清注射液(TanReQing Injection), 鱼腥草注射液(YuXingCao / Houttuynia injection). For deep purplish lips, add 黄芪(Huang Qi, Huangqi, Astragalus root, Radix Astragali seu Hedysari), 三七(San Qi, Sanqi, Notoginseng, Radix Notoginseng), 当归尾(Dang Gui Wei, Danggui tail, Chinese angelica root, Radix Angelicae Sinensis). For constipation, add 生大黄(Sheng Dai Huang, Unprepared Daihuang, Rhubarb, Radix et Rhizoma Rhei)，芒硝(Mang Xiao, Mangxiao, Mirabilite, Natrii Sulphas).

John’s comments:
1) The formula combines that of 麻杏甘石汤(Ma Xing Gan Shi Tang, a decoction formula for the treatment of cough and dyspnea due to wind-heat, consists of 4 herbs), 白虎汤(Bai Hu Tang, a decoction formula for the treatment of excessive heat syndrome in Yang Ming channels and qi system, consists of 4 herbs) and 葶苈大枣泻肺汤(Ting Li Da Zao Xie Fei Tang, a decoction formula for the treatment of phlegm accumulation and retention, consists of 2 herbs) with modifications, mostly addition of herbs. Ma Huang facilitates the flow of the Lung-qi to relieve asthma, and its pungent flavor is good at dispelling exogenous factors. When used in honey-baked form, the effect in relieving asthma and cough is stronger. Shi Gao, pungent and sweet in flavour and extremely cold in nature, acts against excessive heat in Yang Ming channel. Xing Ren, with bitter taste and warm property, helps to move the Lung-qi to the lower part of the body. Huang Qin clears out stagnated heat in the half interior and removes pathogenic factors from Shao Yang channels. Zhi Mu, which is bitter in taste and cold moist in nature, serves to strengthen the action of Shi Gao. Ting Li Zi, pungent and bitter in flavour, very cold in property, removes heat from the Lungs, and relieves asthma. Zhe Bei Mu, bitter in flavor and cold in property, has a strong activity of cleansing heat phlegm away and dissolving accumulation. Pu Gong Ying, bitter in flavor and sweet cold in property, acts on Liver and Stomach channels to clear heat and detoxicate, subdue swelling and dissolve lumps. Chong Lou, bitter in flavor and a little cold in property, acts on Liver to clear heat, detoxicate, subdue swelling, kills pain and relieve convulsion. Dan Pi has the effect of cooling the blood and removing latent heat from the body’s Yin system. Chi Shao removes pathogenic heat from the blood, dissipates blood stasis and relieves pain.

2) The formula is intended to do five therapeutic principles: First, it clears cough and asthmatic cough due to wind-heat. Second, it clears pathogenic heat in the qi system. Third, it has strong emphasis on removing phlegm heat. Fourth, that’s to detox and finally fifth, to cool the blood in the Yin system. This syndrome is definitely more serious and a step further toward deterioration in terms of prognosis. From the point of view of conventional medicine, the symptoms can be similar to that of pneumonia.

5.4.1.4)
Syndrome: Internal shut-down; external collapse
Symptoms: High or low fever, cough, asthmatic short breath, cold limbs, cold sweat, dark purplish finger nails and lips, with deep and fine or non-existing pulse.
Mechanism: Further sinking of toxins, collapse of qi, Yin and Yang.
Therapeutic principles: Strengthens the essential qi to rescue from collapse

Basic formula (Ingredients) & reference dosage:
No. 1) 生晒参15g (Sheng Shai Shen, Sun-dried ginseng, Radix Ginseng);
No. 2) 麦冬15g (Mai Dong, Maidong, Ophiopogon root, Radix Opiopogonis);
No. 3) 五味子10g (Wu Wei Zi, Wuweizi, Schisandra fruit, Fructus Schisandrae);
No. 4) 炮附子10g先下(Boiled first) (Pao Fu Zi, Prepared Fu Zi, Prepared lateral root of Aconite, Radix Aconiti Lateralis Praeparata);
No. 5) 干姜10g (Gan Jiang, Ganjiang, Dried ginger, Rhizoma Zingiberis);
No. 6) 山萸肉30g (Shan Yu Rou, Shanyurou, or 山茱萸, Shan Zhu Yu, Shanzhuyu, Dogwood fruit, Fructus Corni);
No. 7) 炙甘草6g (Honey-baked Gan Cao, Zhi Gancao, Honey-baked licorice root, Radix Glycyrrhizae Praeparata)

Modifications: For severe sweating, add 煅龙骨(Duan Long Gu, Calcined longgu, Dragon’s bone, Os Craconis Fossilia), 煅牡蛎(Duan Mu Li, Calcined muli, Oyster shell, Concha Ostreae). For abundance of phlegm, sputum in throat, greasy coat on tongue, add 金荞麦(Jin Qiao Mai, Jinqiaomai, Wild Buckwheat Rhizome, Rhizoma Fagopyri Cymosi), 苏合香丸(Su He Xiang Wan, a OTC pill for treatment of cold syndrome of coma, consists of roughly 15 herbs (depending on manufacturers)), 猴枣散(Hou Zao San, a OTC powder for treatment of inner phlegm accumulation, consists of roughly 13 herbs (depending on manufacturers)). For injections the following can be selectively used (based on syndrome differentiation): 醒脑静注射液(Xingnaojing Injection), 生脉注射液(Shengmai Injection), 参麦注射液(Shenmai injection), 参附注射液(Shenfu injection), 血必净注射液(Xuebijing injection) and so on.

John’s comments:
1) The formula is a combination of 生脉散(Sheng Mai San, a powder formula for the treatment of impairment of both qi and Yin manifested by short breath, spontaneous perspiration, exhaustion and faint pulse, consists of 3 herbs) and 四逆汤(Si Ni Tang, a decoction formula for the treatment of syndrome of insufficiency of Yang manifested by cold limbs, intolerance to cold, diarrhea, cold-pain of abdomen, mental fatigue and sleepiness, pale complexion and profuse sweat, consists of 3 herbs) with modifications. Sheng Shai Shen (A type of Chinese/Korean ginseng which has been sun-dried) is sweet in flavor and warm in property, acts to replenish qi and promote the production of body fluid, and invigorates primordial qi. Mai Dong, sweet in flavor and cold in property, is used to tonify Yin and promote body fluid production, clear away deficient heat to get rid of restlessness. Wu Wei Zi, sour in flavor and warm in nature, is used for astringing the Lungs to stop sweat. Fu Zi, pungent and hot in the extreme, acts on channels of the Heart, Kidneys and Spleen, helping to warm the Yang and qi and recuperate the depleted Yang to rescue from collapse. Gan Jiang, functions in warming Yang of the middle portion and eliminating interior cold. Therefore it’s suitable for vomiting and diarrhea due to cold of the insufficiency type. Shan Zhu Yu, sour in flavor and slightly warm in property, induces astringency to arrest excessive loss of body fluid. Gan Cao, in honey-baked form, strengthens the Spleen and replenishes qi. It is used in assisting Fu Zi to recuperate depleted Yang and promote blood circulation, in assisting Gan Jiang in warming and restoring Yang of the middle portion, in reducing toxin of Fu Zi, in relieving the extremely pungent property of Fu Zi and Gan Jiang so as to make it possible to warm Yang and remove Yin cold without injuring Yin fluid.

2) The formula achieves the result of replenishing qi, warming the Yang energy and astringing Yin. This stage is of the extreme one as the patient has exhausted the body’s qi, Yin fluid and Yang energy during the course of battle with the pathogenic factors. The first priority is to quickly replenish qi, recuperate Yang and promote body fluid production. The second direction is to astringe further exhaustion through excessive perspiration.



Postscript:
I have written on the general applications of traditional Chinese medicine in treating Avian/Bird Flu related symptoms. Some advantages of TCM have been outlined. With the ever increasing threat of human-to-human pandemic I see a need in better awareness of using traditional medicine to reach wider scope of people.

One of the advantages of using Chinese herbs is that the patient, having flu-like, or pneumonia-like symptoms, who may or may not be Bird Flu virus related, can immediately take Chinese herbs once his or her syndrome is properly diagnosed with TCM diagnostic method. The diagnostic method doesn’t rely on availability of test kits, machines, and can be done in 10 minutes. Of course, a properly trained TCM physician has to do the job in diagnosing. In the case of suspected Bird Flu, medical personnel can be trained to recognize the most prominent features of identifying the commonly manifested different syndromes.

There are purposes for this article:
1) To outline the different syndromes manifested by human beings infected by Bird Flu virus. There are of course some other syndromes which can share certain similarities to that of this policy. There are at least two policies which have been translated into or written in English: (1) The policy issued by 441-443 of issue No. 6, 2005 of 天津中医药 Tian Jin Zhong Yi Yao (Tianjin Chinese Medicine & Medicinals) journal, translated by Bob Flaws and; (2) “The potential Avian Flu epidemic” by Jake Paul Fratkin, April, 2006 . They are very good references; they would have been better if elaborations and explanations were given.
2) To explain and elaborate how different herbs, with different properties, flavours, channel tropism, and effects are applied cohesively into a formula that works hand-in-hand to treat a particular syndrome. There are certainly not many writings focus on how herbs actually work on our human bodies.
3) As mentioned above, to emphasize how Chinese herbs can be applied with or without knowing the existence of H5N1 virus. By proper diagnosis of syndromes based on many symptoms/manifestations, a herbal formula can be custom-tailored for treatment.

Over-The-Counter Prescriptions:
Another section of the article, section 5.4.2, focuses on the application of OTCs (Over-The-Counter) according to various syndromes. There are six categories of the OTCs, in the forms of pills, boluses, oral solutions, powders and injections. The categories are: 1)解表清热(Jie Biao Qing Re, Exterior-relieving and heat-clearing, 3 OTCs suggested); 2)清热解毒(Qing Re Jie Du, Heat-clearing and toxins-clearing, 4 OTCs suggested); 3)清热开窍化瘀(Qing Re Kai Qiao Hua Yu, Heat-clearing, resuscitation and clearing blood stasis, 6 OTCs suggested); 4)清热祛湿(Qing Re Qu Shi, Heat-clearing and dampness-removing, 2 OTCs suggested); 5)止咳化痰平喘(Zhi Ke Hua Tan Ping Chuan, Cough-arresting, phlegm-resolving and asthma-relieving, 4 OTCs suggested); 6)益气固脱(Yi Qi Gu Tuo, Qi-supplementing and exhaustion-astringing, 3 OTCs suggested). They can be convenient in prevention as well as treatments at various stages. I do not translate nor elaborate on them because these OTCs are not normally available outside China.

Notes:
1) The modifications to the suggested formulae must be based on differentiation of syndromes, i.e. taking into accounts the properties, flavours and channel tropism of the herbs.
2) Directions: All the ingredients are to be decocted in water for oral dose. Modern form of herbal preparation includes fine powder extracted from individual herbs; without the need for inconvenient decoction.
3) Capitalization of the first letter of internal organs in this writing refers to the channels/systems/organs; not just the physical organs alone.

References and more information:
1) Ministry of Health of the People’s Republic of China: www.moh.gov.cn
2) 人禽流感诊疗方案(2005版修订版); issued on November 23rd, 2005, by the Ministry of Health, People’s Republic of China
3) World Health Organization, WHO’s perspectives: Avian Influenza: http://www.who.int/csr/disease/avian_influenza/en/
4) The Potential Avian Flu Epidemic, By Jake Paul Fratkin; Acupuncture Today, April, 2006, Vol. 07, Issue 04
5) Bird Flu and Chinese Medicine, By Bob Flaws, Acupuncture Today, October, 2006, Vol. 07, Issue 10

Abstracted, translated, compiled and analyzed by John Lew.