Spring Open House.

If you are here for the next installment in the flu posts, that will be next week.  I have to take care of some local business first. 

We had so much fun at the Winter open house that we decided to set a date for a Spring open house.   I haven’t done much to circulate that event,  because I’ve been preoccupied getting ready for the second set of street medic trainings which start on Saturday.

I thought about changing the name of this gathering because the modern definition of “open house” meaning has shifted away from its historical meaning , but I am pretty stuck on this term and I am going to tell you why.
One of my favorite Irish healers  was  Biddy Early  who was known for keeping an “open house” and often hosting the community cuaird.  The cuaird was basically a house party for commoners who didn’t have their days off for socializing during fancy afternoon tea parties.

The host literally left their kitchen door open and set chairs by the fire. Neighbors would walk in, take a spot by the fire, and they would spend the evening  making music, dancing, sharing stories in their native Gaelic, drinking a bit, and engaging in revolutionary political rhetoric. These open house parties contributed to the preservation of the  Irish culture and language, during a time when English colonizers were trying really fucking hard to stomp it out.

Biddy Early was a special kind of healer  called a ritual healing specialist,  but she was also a bit of an activist.  She never took a bit of money for her cures, but traded for poteen and food which she then shared with others through good old-fashioned hospitality.

It was said that she never turned away a tired traveller and many a passer-by was offered a jug, some food, and a seat in front of her warm fire.  It was a fairly nifty way of avoiding taxation and redistributing the wealth. She was also known for taking on landlords and law officials during a time when the wealthy colonizers were bearing down on the poor.

So  anyway a 17th century Irish activist is my  inspiration for my open houses and kind of my life, really.  But don’t call me biddy.  That’s got turned into a slur used against Irish immigrants.  I don’t love it.

I have taken the concept a  bit further by setting it up as a bartering event.

To participate as a “vendor” the only rule is that you must be primarily prepared for bartering.  I sent someone home one year who came with a “cash only” sign.  That’s just not how this one works. I also make sure that everyone who performs walks away with something from me and think I am going to make it a rule that  every vendor has to do that.

We had a lot of fun in December.  I don’t think that much cash was exchanged but we all walked out with nice piles for holiday gift-giving.  Plant babies were very popular trade items.  I got two coleus. It’s open to anyone who has a good or service to negotiate with.  In the past we have had:

Professional Artists
Hobby Crafters
Soapmakers
Bakers
Jelly Makers
Gardeners
Photographers
Chainmail

If you are one of those people blessed with more money than time, you can absolutely come buy things and stick a little cash in the performer’s tip jar.   My daughters know a lot of really talented people and there was some beautiful art at the last open house.  They surprised me by buying  me one of the paintings I really liked.

If you aren’t in to any of this.  I set up the bar with mixers and my bitters blends for a BYOB cocktail party. Bring a bottle if you can afford it, throw some darts,  and maybe engage in a little revolutionary political rhetoric.  

And who are we kidding, Steve will feed us because that’s what Steve does.

When Not to Use Elderberry: Using a Little Discernment

(This is the second in what will be a series of posts about acute illness and herbal adjuncts.  If you haven’t read the introduction you might want to go back and do that. )

I’ve been struggling with how to start this next installment on viral illness and then I found the following statement on a website. You are just going to have to trust me on this I am not going to link to a site full of affiliate adds for supplements you don’t need, and my intention is not to start anything with the authors.

The article said, “Elderberry also upregulates IL-6, IL-8 and TNF, suggesting an indirect effect on viral immune response in the body. Interestingly, elderberry was shown to have this effect but not its major bioactive compound, cyanidin 3-glucoside.”

To begin with, I don’t consider that anthocyanin to be the major bioactive compound of this plant.  I only use elderflower, and I consider its major bioactive constituent to be pectic polysaccharides, but that’s absolutely not important to this conversation.

Honestly though,  I am relieved by this statement.  I am more likely to use black currants which contain the same anthocyanin which has the same effect on viral replication[i] without upregulating the primary proinflammatory cytokines.  To explain why I find that preferable I am going to talk about the cytokines that are specifically mentioned in that statement.

What Are Cytokines?

Cytokines are just messenger peptides that mediate the inflammation pathways by carrying messages from cell-to-cell.  Some are  proinflammatory, some are anti-inflammatory,  and some that can go either way depending on the situation.

IL 6 and TNF-alpha are some of the more active proinflammatory cytokines and IL-8 is specific kind of cytokine called  a chemokine which are involved in chemotaxis or the recruitment of white blood cells to an area.  When I was in school I remembered this for tests by thinking of them as chemical taxis.

The tiny peptides traveling between these cells are cytokines.

Is Upregulating Cytokines Beneficial?

The answer to this question is not always. I will start by discussing why I wouldn’t necessarily want to upregulate IL-8 which is a chemokine involved in recruiting white blood cells to an area.

Stanford physician Catherine Blish has studied the hyperinflammatory response to severe influenza in pregnancy extensively attempting to understand why many pregnant women become extremely ill when exposed to influenza. She has stated that abnormally elevated chemokine levels common in pregnancy draw too many white blood cells to the lung. “That’s a bad thing in a lung where you need air space.” Getting the flu during pregnancy, especially pandemic strains such as those that caused the pandemics of 1918, 1957 and 2009, carries a heightened risk for pneumonia and death.”[ii]

What she’s talking about here is a cytokine storm. I have a vested interest in this story because it was this flu that killed my great-grandfather Roberts. The clinical presentation of the storms was first associated with the 1918 flu and included accounts of patients drowning because their lungs filled with fluid and blood [iii] My great-grandfather had the flu, but was still well enough to be up and working and literally dropped dead in the field. So it must have hit him fast.

In 2013 researchers examined the lung tissue of 50 victims of 2009 H1N1 who had died of cytokine storms had “remarkably” elevated levels of IL-1 receptor antagonist protein,IL-6, tumor necrosis factor-alpha, IL-8, monocyte chemoattractant protein-1, macrophage inflammatory protein 1-beta, and interferon-inducing protein-10 [iv]  which undoubtedly contributed to the over recruitment of white blood cells.

These cytokine storms trigger a type of sepsis which is an autoimmune event involving an amped up immune system response that results in a fatal pneumonia. It is usually associated with H1N1,but coronaviruses have sparked storms, as well.  For what it’s worth the 2019-nCoV includes a risk of what some researchers are calling Wuhan Pneumonia which seems to be caused by some sort of cytokine storm.

Now let’s stop and think for a moment about what we have already read.  Three of the seven cytokines I listed up above are those the crappy, cherry-picked marketing article mentioned elderberry upregulating. It gets worse for elderberry because researchers found specifically that areas of the lungs that had high bacterial infection also had high levels of IL-6, IL-8[v], so it doesn’t seem prudent to risk exacerbating that.

Since the risk of cytokine storm is not common,  I am going to step back a moment to talk about IL-6 and TNF-A.  These are both what they call endogenous pyrogens in that they trigger a fever response as a defence mechanism to pathogens.  They also act on nociceptive sensory neurons in the body to initiate the sensation of pain.   So even in a flu where there is not a known association with cytokine storm, we still want to observe the type of discomfort a person is experiencing and pick our adjuncts accordingly.  There is no sense in poking a system that’s already in overdrive.

This B/Washington strain that the flu vaccination botched was a particularly hot and achy strain.   Several of my clients who normally take elderberry during a cold, told me they thought their syrup was making it worse and asked if I had other ideas.  This makes sense to me giving the fact that it elevates cytokines known for initiating those prodromal signs and symptoms.

In the name of making better more nuanced choices, you also want to take into account any health conditions that you don’t want to exacerbate. After reading the Blish interview and the associated study I am going to start recommending that pregnant women not use it during the flu season because they are already at an increased risk of hyperimmunity.[vi]

Honestly I wouldn’t recommend elderberry to a client that had any autoimmune disorder, but I am a safety girl and I have enough tricks up my sleeve to work without it.

Black currants are definitely one of those tricks, but I am a big fan of getting a wide variety of anthocyanins from blackberries, blueberries, raspberries, and strawberries.

So what about taking elderberry prophylactically?

If you just  are using elderberries as tonic when there is no viral complication, is that such a big deal? There are some concerns about doing that.

We know that “excessive or persistent cytokine production results in deregulated immune activation and plays a role in both the initiation and the amplification phases of immunopathologies.”[vii]  This means it is possible  that  prolonged upregulation of these primary inflammatory cytokines could contribute to initiating or exacerbating an autoimmune disease.   I have worked with clients who believe it triggered a flare for them, although I haven’t seen that with elderberry nearly as often as I have echinacea.

TNF-α, and IL-6 are already elevated in people with rheumatoid arthritis and contribute to chronic inflammation of the synovial tissue, joint dysfunction, and consequent tissue damage in the joints.   So persistent upregulation could exacerbate their symptoms of chronic inflammation.

There are no human studies that have shown long-term use is safe.  There is one study that I can find where the subjects took it for three weeks, but they were looking at diabetes markers as the end result and did not assess final C-reactive protein levels or any other marker of inflammation. Because I know from experience that autoimmune diseases are really no fun, I don’t feel comfortable recommending it without knowing for sure that I am doing no harm.

Also, you never know when you are going to be exposed to a virus that might be associated with the storms and they really don’t know why they happen.  Some researchers believe it has to do with age and say children or the elderly are most susceptible, but most of the victims mentioned in that 2013 paper, were in their mid 30’s.  My great-grandfather was also a younger man with no health complications that we are aware of.  So if we know that an illness associated with these storms is circulating, we want to be cautious.

What really frustrates me to me is that there are plenty of herbs out there that interfere with viral replication. Research in this area is off the charts, right now.  We don’t NEED elderberry. So why is the elderberry craze persisting?  Call me cynical, but I think the answer to that has something to do with marketing.

I am not saying that everyone who tries to sell you elderberry knows this stuff. It takes a long time to understand the interaction between herbs and cytokines and I still consider myself a novice.   Some people out there have just latched on to the idea that just because something is natural it is safe, and they don’t necessarily have the education and experience to know better.

None of this is meant to say you should never use elderberry. I am just using it as an example to illustrate some of the questions you should be asking yourself about every herbal adjunct you use.  How does it work, when shouldn’t a person use it, and are their safer alternatives?

Basically what I have decided concerning the use of elderberry is that while I can’t  prove that any of these things will be a problem, I can’t prove that they won’t  be.   That should be a deciding factor of any  risk-benefit analysis.

Edited 02 Feb. 2020

I am editing this post to share my friend Thomas Easley’s  feedback that this article “maybe even underemphasizes the potential consequences of IL6 in promoting th17 and suppressing Treg differentiation. If you want to burn an infection out with your immune system use elderberry – but beware the risk of catching everything on fire!”   He shared this information about IL6 as a regulator of Treg/Th17 balance. 

I wanted to share this article, but I have also had a lot of messages about where to study this sort of information about herbs.  If you take my local consultation class I teach the basics you need to be an informed consumer. If you want to learn clinical application, I strongly suggest checking out Thomas’ program.  He will put you on the right path.

References:

[i] Ehrhardt, Christina, et al. ‘A Plant Extract of Ribes Nigrum Folium Possesses Anti-Influenza Virus Activity In Vitro and In Vivo by Preventing Virus Entry to Host Cells’. PLoS ONE 8, no. 5 (23 May 2013). https://doi.org/10.1371/journal.pone.0063657. and Ikuta, Kazufumi, Koichi Hashimoto, Hisatoshi Kaneko, Shuichi Mori, Kazutaka Ohashi, and Tatsuo Suzutani. ‘Anti-Viral and Anti-Bacterial Activities of an Extract of Blackcurrants ( Ribes Nigrum L. ): Anti-Microbial Activity of Blackcurrants’. Microbiology and Immunology 56, no. 12 (December 2012): 805–9. https://doi.org/10.1111/j.1348-0421.2012.00510.x.

[ii] Digitale, Erin. ‘Immune Response Turned up High by Flu during Pregnancy, Stanford/Packard Study Finds’. Stanford Medicine News Center (blog), 22 September 2014. http://med.stanford.edu/news/all-news/2014/09/immune-response-turned-up--not-down--by-flu-during-pregnancy--st.html.

[iii] Kobasa D, Jones SM, Shinya K, et al. Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus. Nature. 2007;445(7125):319–323. doi:10.1038/nature05495.

[iv] Gao R, Bhatnagar J, Blau DM, et al. Cytokine and Chemokine Profiles in Lung Tissues from Fatal Cases of 2009 Pandemic Influenza A (H1N1). The American Journal of Pathology. 2013;183(4):1258–1268. doi:10.1016/j.ajpath.2013.06.023.

[v] Ibid.

[vi] Kay AW, Fukuyama J, Aziz N, et al. Enhanced natural killer-cell and T-cell responses to influenza A virus during pregnancy. Proceedings of the National Academy of Sciences. 2014;111(40):14506–14511. doi:10.1073/pnas.1416569111.

[vii] Salvi V, Gianello V, Tiberio L, Sozzani S, Bosisio D. Cytokine Targeting by miRNAs in Autoimmune Diseases. Frontiers in Immunology. 2019;10. doi:10.3389/fimmu.2019.00015.

Stages of Acute Illness: An Integrative Perspective

I spend a lot of time wrestling with false binaries, but the one that is particularly annoying during cold and flu season is the idea that natural health modalities  and conventional modern medicine are on opposite ends of a spectrum.  The two modalities can and should be working together to create the best outcomes for people.

I really don’t know what fuels this divide?  I mean some of it is undoubtedly marketing competition and some of it is probably ego driven dogma and a lot of other nonsense.  None of that is in the best interests of the people I serve.

I know some of what I say below will be difficult for some of my colleagues to hear. I know we are not afforded the same respect by the general medical establishment as I am suggesting we exhibit. Ultimately our responsibility is to support our clients to the best of our ability and that means setting our egos aside, even if the physicians don’t.

Maybe that will change, soon? Research scientists are hard at work digging up herbal adjuncts to conventional treatments and alternatives to antibiotic. Maybe  17 years from now (maybe 20 in Iowa) when today’s biomedical research actually filters down to actual clinical practice.[1] we will finally get some respect.

But I’ve got news for you. You have to earn respect and the shoddy excuse for herbalism that proliferates on the Internet, isn’t going to do that for us. We need to do better.

I’ve been working with acute illness and herbs for well over over twenty years now. I admit that I think one of my superpowers is working with herbal interventions to make people more comfortable and to ward off secondary infections.  Neither of my younger kids (18 and 15)  has ever needed antibiotics.  (Note that I said needed.  If I even suspected they had secondary infection, I would take them to a doctor immediately.  There’s no reason a child should suffer due to a parent’s irrational opposition to conventional medicine. )

Due to the  coronavirus scare, I’ve taken a lot of my cold and flu posts down and am going consolidate them in a more cohesive series.

This is the first installment. It is a summary of my integrative view of the stages of acute illness including a look into the emotional needs that a person might  experience during each stage derived from my sociology classes.  This primarily applies to acute illnesses but certain aspects such as sickness behaviour present with chronic illness as well.  I am including a few very simple comfort measures you can take during some stages,  I will be writing more on this later.

Exposure (Incubation Period)If you live around children, or leave your house regularly, you are going to be exposed to pathogens.  Once  you are exposed to a virus it begins replicating in your system.  With influenza, this stage lasts until you begin to experience prodrome symptoms within 24 – 72 hours. Other viruses have a longer incubation period.  Most of the time you won’t experience signs or symptoms during this stage.

Onset (Prodromal Period)

During this stage you begin to experience prodrome symptoms. That means these are signs and symptoms that indicate the immune system is responding to viral replication as opposed to the characteristic symptoms caused by a specific virus.

One of the body’s defense mechanisms is to elevate your body temperature.  Normal fevers between 38° – 40° C (100.4° and 104° F) are a healthy expression of the immune system and do not need to be treated.[2]  Fever is often accompanied by body aches and chills, and it’s nice to provide comfort measures like a hot water bottle at the feet and an icebag tucked behind the neck.   You also might notice fatigue, swollen lymph glands, or aches and pains caused by inflamed mucosal tissue.  I make a topical spray from mint that many people say helps them through this stage

Sometimes a good strong immune response fights off the invading pathogens and you never experience strain specific signs and symptoms. I think most moms have experienced a child running a fever for a day or so, without any other symptoms.

Emotionally people begin to feel “off.”   They might ask questions like “Do I feel feverish to you?” or “Is it cold in here?” They might consult with other people in their social circle to find out what illnesses have been in circulation and what symptoms to expect.  At this point I feel like many people are just looking for confirmation that their symptoms are not specific to them.

As they begin to experience signs and symptoms some people may even seem afraid or anxious. They  might find comfort in reassurance that other people have been recovering quickly without expensive medical care.

This is a time to begin pumping the liquids into people in the form of infusions, decoctions and broths. Some people start frontloading supplements like zinc or Vitamin C.   The signs and symptoms haven’t differentiated enough to turn to specific remedies.

Active Phase (Periods of Illness and Decline)

The active phase of the illness is when the pathogen count in your body climbs to its highest point,  signs and symptoms are most severe, and you are the most contagious.This stage peaks and declines as the number of viral particles start to decrease.  It is during the period of decline that you are particularly susceptible to secondary bacterial infections.

At this stage people might self-medicate with over the counter (OTC) medicine such as decongestants or NSAIDs.  Self-medication accounts for a lion’s share of all healthcare dollars in the United States.The predominant market  of botanical therapeutics practiced in the US focuses on replacing OTC medications with herbal alternatives.

It goes without saying that any time that you feel overwhelmed by an illness, you should seek out medical care. If your medical professional diagnoses you with a secondary infection they will generally prescribe an antibiotic unless they think it is self-limiting. (It’s not very common here in Iowa yet, but many physicians have stopped prescribing antibiotics for childhood ear infections.) Take the prescription. They are less expensive and more accessible than herbal alternatives, and they usually work faster.

What a physician often  doesn’t know is that there are  herbal adjuncts that can increase the effectiveness of your antibiotic prescription often by interfering with communication (quorum sensing) in a bacterial colony and reducing the likelihood of recurring chronic infections[4]

There are also herbal alternatives [5] for people who are told by their physicians they have viruses or self-limiting bacterial infections. I am not going to get into specifics in this post.  The measures are often strain specific and specific to the individual’s constitution. I will not give you  one size fits all answers.

If you speak to an herbal practitioner who questions your physician’s advice or tells you not to finish your prescription, that’s a red flag.  Not finishing a prescription may contribute to the growth of antibiotic resistance bacteria in your body, and it is irresponsible advice. 

When people do seek out professional help  they are looking for validation, explanation of symptoms in simple terms, and preparations that might lessen the intensity and duration of symptoms. That’s why they get so frustrated by doctors who tell them they have a virus and to go home.


Another emotional characteristic of this stage called “sickness behavior”  refers to the physiologically driven withdrawal from activities and social interaction.[3] It is a “normal” expression of the active, contagious stage of the illness.  This is often complicated by the fact that this is the phase when people often are too ill to perform adequate self-care.

Check in on your people. Take them a crockpot of soup or a hot thermos of tea. Because they don’t feel like reaching out at this stage but they may need help.

Recovery and Convalescence:

This is the stage of illness during which one rests and rebuilds strength, after the active stage of the illness has passed.  The duration varies greatly. Some people may experience a post viral rash or a cough that persists for 3-8 weeks.

Unfortunately, not many people have the luxury of taking any significant time off their job to recuperate. We can pay especially close attention to our nutrition during this stage and there are herbal preparations that are beneficial especially for people who have taken antibiotics.

Some people may experience a nagging malaise or feel otherwise emotionally depleted. Physicians call “post viral syndrome.”  The exact etiology is largely unknown although it’s been theorized that its due an overactive immune system and seems to be related to their emotional state at onset.

Prevention or Non-pharmaceutical Intervention (NPI)

It’s worth mentioning that your immune system is weakened at this point, so I will end this the same lecture about prevention my kids get all the time.  Note this goes a little more in depth than the CDC suggestions which are all tied up in red tape, but all of these measures will help you have a less eventful cold-and-flu season.

Sanitation: Frequent, thorough handwashing with soap and water is the most important NPI but that is not the only preventative measure you can take.  The World Health Organization recommends routine cleaning of frequently used surfaces and objects to reduce influenza transmission. Sterilize things everyone touches like toothbrushes, computer equipment, doorknobs, and faucet handles, once weekly during the flu season and daily when people are sick. Also wash your produce, because you don’t know who has touched it.

If you go out when you are sick, take a container of cleaning wipes with you and clean up after yourself. Think about that person who pushes the shopping cart after you who doesn’t have insurance.

Vaccination: The flu vaccination is notoriously ineffective. That doesn’t mean you shouldn’t get it.  I  just assume that it will not work and still take proper preventative measures.  Some vaccinated people may get the flu and barely have any symptoms, but still be able to spread the virus to others. The flu vaccination also does not make you immune to many viruses including adenovirus, rhinovirus, coronavirus, or coxsackievirus.  Basically what I am saying here is having been vaccinated is not an excuse to be an inconsiderate public health risk.

Isolation: Self-imposed quarantines are probably the most effective way to halt the spread of the disease. You are contagious until you are unmedicated and afebrile (without a fever). I like to wait a minimum of 24 hours. I get that we work in an inequitable society where people either don’t  have sick days or are penalized for taking their sick days.  Just do the best you can and try to stay away from people when you are ill.

If you must go out when you are ill, wear a surgical mask to protect other people from illness.  It’s important to note though that masks only stop large-droplet spray. Fine aerosolized droplets still travel through the masks and remain suspended in the air for some time, so even if you are wearing a mask, cough and sneeze into your own arm to try to contain that a little.

My friend who is a surgical nurse also told me I should point out that the masks are much less effective after they get damp from breathing through them so you should be switching them out every half hour or so.

Humidity: Raising the humidity in a room may reduce mobility of these smaller droplets.[6] It’s worth noting that this is not a new discovery, however in the past the concern about bacterial build-up in humidifiers has led hospitals to steer clear of them. While using a crockpot to simmer herbs the way I do is probably a fire hazard, at least I am thoroughly washing the crock every 48 hours.

Stay Hydrated:  The mucosal tissues in your body need  adequate fluid intake to maintain their integrity and to produce mucin in response to increased pathogenic presence.  I recommend drinking a lot of warm herbal beverage teas during the cold winter months.

Stay Warm:   While this advice used to be written off as an old wives’ tail, there is evidence that cold exposure suppress immune function by lowering the innate immune response, especially to rhinovirus.[7] Exposure to cold also constricts the respiratory tract slowing mucociliary clearance of pathogens trapped in mucus which may contribute to developing secondary respiratory infections.[8]

Manage Stress:  I know this is a lot easier said than done.  I hate having to suggest it to people who are struggling to stay afloat in an inequitable, unjust society, but stress does suppress immune function.

Exercise: There’s a school of thought out there that vigorous exercise suppresses immune function, but that’s been dismissed by a lot of researchers and in fact probably improves immunity by directing lymphocytes to the peripheral tissue.[9]

Herbal Preparations:  There are some immunomodulators which prime your immune system to work more efficiently when you are exposed to a pathogen. These are often herbs I think of as food, like astragalus, burdock root, dried mushrooms.  Some of these, like astragalus, aren’t very useful when you are sick unless your system is just too weak to fight a pathogen off.

Immunostimulants like echinacea and elderberry mostly interfere with viral replication or suppress inflammation pathways, so they are more useful after exposure and the long term prophylactic use is contraindicated in people with autoimmune issues or other complicating factors.

I would suggest you talk to an herbal professional about  your particular situation, but not all of herbalists are created equal.  Feel free to email me at stephany@naturallysimple.org for a referral in your area or to talk about my herbal wellness class.  I offer scholarships and work-trade opportunities so don’t let money be a factor in reaching out to me.

References:

[1] 1. Balas EA, Elkin PL. Technology Transfer From Biomedical Research to Clinical Practice. Evaluation & the Health Professions. 2013;36(4):505–517. doi:10.1177/0163278713508135.

[2] Seattle Children’s Hospital. ‘Fever - Myths Versus Facts’. Accessed 2 February 2020. https://www.seattlechildrens.org/conditions/a-z/fever-myths-versus-facts/.

[3] Kelley, Keith W., Rose-Marie Bluthé, Robert Dantzer, Jian-Hua Zhou, Wen-Hong Shen, Rodney W. Johnson, and Suzanne R. Broussard. ‘Cytokine-Induced Sickness Behavior’. Brain, Behavior, and Immunity, Biological Mechanisms of Psychosocial Effects on Disease: Implications for Cancer Control, 17, no. 1, Supplement (15 February 2003): 112–18. https://doi.org/10.1016/S0889-1591(02)00077-6.

[4]Vasudevan, Sahana, Shogan Sugumar Swamy, Gurmeet Kaur, S. Adline Princy, and P. Balamurugan. ‘Synergism Between Quorum Sensing Inhibitors and Antibiotics: Combating the Antibiotic Resistance Crisis’. In Biotechnological Applications of Quorum Sensing Inhibitors, edited by Vipin Chandra Kalia, 209–25. Singapore: Springer Singapore, 2018. https://doi.org/10.1007/978-981-10-9026-4_10. and Moore et al. Microbiological safety of spices and their interaction with antibiotics: implications for antimicrobial resistance and their role as potential antibiotic adjuncts. Food Quality and Safety. 2019;3(2):93–97. doi:10.1093/fqsafe/fyz008.

[5] Humpherys, Brayden, and David D Busath. ‘Anti-Influenza Nutraceuticals: Antiviral and Anti-Inflammatory Effects’ 4, no. 3 (2019): 15.  and Akram, Muhammad, et al. ‘Antiviral Potential of Medicinal Plants against HIV, HSV, Influenza, Hepatitis, and Coxsackievirus: A Systematic Review’. Phytotherapy Research 32, no. 5 (May 2018): 811–22. https://doi.org/10.1002/ptr.6024. and Lee, Ju-Young, et al. ‘Herbal Medicines with Antiviral Activity Against the Influenza Virus, a Systematic Review’. The American Journal of Chinese Medicine 46, no. 08 (January 2018): 1663–1700. https://doi.org/10.1142/S0192415X18500854.

[6] Binder, Leah. ‘This Inexpensive Action Lowers Hospital Infections And Protects Against Flu Season’. Forbes, 17 October 2019. https://www.forbes.com/sites/leahbinder/2019/10/17/harvard-researcher-says-this-inexpensive-action-will-lower-hospital-infection-rates-and-protect-us-for-the-flu-season/#7417a72a1824.

[7] Foxman EF, Storer JA, Fitzgerald ME, et al. Temperature-dependent innate defense against the common cold virus limits viral replication at warm temperature ... Proceedings of the National Academy of Sciences. 2015;112(3):827–832. doi:10.1073/pnas.1411030112.

[8] Mourtzoukou, E. G., and M. E. Falagas. ‘Exposure to Cold and Respiratory Tract Infections’. The International Journal of Tuberculosis and Lung Disease 11, no. 9 (2007): 938–943.

[9] Campbell, John P., and James E. Turner. ‘Debunking the Myth of Exercise-Induced Immune Suppression: Redefining the Impact of Exercise on Immunological Health Across the Lifespan’. Frontiers in Immunology 9 (2018). https://doi.org/10.3389/fimmu.2018.00648.