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RHR: Everything You Need to Know about Coronavirus, with Dr. Ramzi Asfour


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With its rapid spread, the coronavirus is a topic that’s on everyone’s minds. In this episode of Revolution Health Radio, I talk with infectious disease specialist Dr. Ramzi Asfour about the coronavirus: what it is and how you can protect yourself against it.

Revolution Health Radio podcast, Chris Kresser

In this episode, we discuss:

  • The spread of the coronavirus
  • Testing for the coronavirus
  • How infectious the coronavirus is
  • How to protect yourself against infection from the coronavirus
  • Supporting your immune system to prevent infection
  • Three recipes for immune-boosting botanicals

Show notes:

Hey, everybody. This is Chris Kresser. Welcome to another episode of Revolution Health Radio. This week, I’m excited to welcome back Dr. Ramzi Asfour as my guest. You may recall that I did a podcast with Ramzi a little while ago on the connection between Lyme disease and gluten intolerance and celiac [disease], which was really fascinating. We had originally planned to do part two of that podcast because there was a lot of material that we hadn’t covered today, but given the coronavirus outbreak and given Ramzi’s background as an infectious disease specialist who has a lot of experience with viral illness, we thought it would be better to do a show on coronavirus: what it is, how to protect yourself, and how to treat it if you get infected. So that’s what we’re going to talk about today.

Ramzi Asfour is a board certified infectious disease and internal medicine doctor. He graduated from New York Medical College, then completed an internal medicine residency program at California Pacific Medical Center, followed by a fellowship in infectious diseases at UCSD [University of California San Diego]. He’s worked for the World Health Organization [WHO], Columbia University in South Africa, and UCSD. Prior to attending medical school, Ramzi majored in genetics at UC Davis [University of California, Davis] and he’s currently assistant clinical professor of medicine at UCSF [University of California San Francisco]. And he is a staff physician at California Center for Functional Medicine.

So I hope you get a lot out of this podcast. This is obviously a topic that’s on all of our minds. And there’s a lot of good information out there. There’s some not so good information out there. So I wanted to have this podcast with Ramzi so we could just give you the evidence-based information that you can use to protect yourself and your family. So let’s dive in.

Chris Kresser:  Ramzi, it’s such a pleasure to have you back on the show, although I wish the circumstances were a little bit more positive.

Ramzi Asfour:  I agree. Thank you, Chris. It’s always a pleasure to be on your show. And it is, yeah, quite an interesting time.

Chris Kresser:  So, originally, we were going to do part two of the excellent series you started on looking at the connection between Lyme disease and gluten intolerance and celiac [disease]. But given the current coronavirus outbreak, we decided that, especially given your background as an infectious disease doctor, this time would be better spent talking about the coronavirus and the current status of the outbreak as of Tuesday, March 3, when we’re recording this, and, of course, share some tips for what people can do to protect themselves and what they can do if they do become infected or develop a cold or a flu. Which I think part of the issue here, which I’m sure we’ll cover, is how do you know if you have it?

But let’s spend the first part of the time talking about coronavirus in general. Explain what it is, covering the epidemiology, current status, what’s happening globally right now, and then some protective measures that people can take. And then I will spend some time talking about further preventative methods and also treatment from my perspective as an herbalist.

The Spread of the Coronavirus

Ramzi Asfour:  Sounds great, Chris. So, first of all, coronavirus, everybody knows that the name is now called COVID-19. And some people are also referring to it as SARS [severe acute respiratory syndrome] COVID 2. And, just some background, its genetic material is called RNA. It’s similar to some other coronaviruses that are present in bats. And with SARS, you might remember there was, it was thought to be a bat origin, but then it transmitted to humans through these creatures called civet cats, which are apparently a delicacy in some parts of the world.

And MERS [Middle East respiratory syndrome], which is also a coronavirus, was through the single hump camels, or the dromedary camels that were an intermediate host. The epidemiology appears that in China, the spread is starting to slow down. There are draconian restrictions in places we know, which is not going to happen in Europe or the United States, for sure. But that’s a good sign that the epidemic seems to be slowing down. The number of new cases being reported and the number of deaths seems to be decreasing. That is not the case in Europe. Obviously, people have heard about Italy in the media. I just read that museums in Milan are opening again, but people are being advised to maintain three feet of distance apart. That is probably reasonable. But there is significant activity in northern Italy, especially. And in France, you might have heard they closed the Louvre Museum.

And I was just reading the news, in France, they’re talking about canceling all big sporting events, concerts, [and] everything throughout the country. They haven’t made a decision yet. But that is something that could certainly happen. And that’s what happened in China. Many schools in the south of France in Nice, [which] are close to the Italian border, have already been closed since last week. Also, large gatherings have been banned in those areas. So that is a little bit of what we might be looking forward to, unfortunately, in our country, and especially on the West Coast. The spread most concerningly is that there are new infections popping up. There were three probable new cases yesterday in Santa Clara County, so in Silicon Valley.

We already knew of two confirmed cases there, without spread or without contact with travelers or without the travel history, to one of the now five countries that are at high risk. That’s:

  • South Korea
  • Italy
  • Iran
  • Japan
  • And, of course China, including Macau and Hong Kong

So we also know that there are still some flights. For example, I actually saw a patient yesterday who just arrived from the Seychelles on vacation. I asked her, “What was it like in Heathrow Airport on [your] transfer over?” And she said, “Well, quite a few people were wearing masks, including customs officials and airport staff, security personnel, and passengers.” But when she landed in San Francisco, there was a flight from Hong Kong that [had] just [gotten] in, and about 80 percent of those people were wearing simple face masks at least. We’ll talk about that and the level of protection you might get from that later.

The other, so that the spread is probably increasing, we’re still having a lot of international travel. There are a few cases in New York. There were some travelers from Milan that just landed in New York a couple of days ago, and they’re reporting symptoms. But they can’t get a test done. So, and that’s a problem, not being able to get a test done. So the nursing home outbreak in King County near Seattle is also very concerning, especially because that population is older and seems to be much more at risk from this virus.

So we have a major confluence of factors here. We’ve got some cases popping up on the West Coast, especially, but some signs that even on the East Coast, including Florida, there are some cases without a travel history that are popping up. So I suspect we’re going to see widespread activity of this virus in lots of parts of this country, especially on the West Coast, in the Bay Area, in the Seattle area, and probably in Portland, too. [It] seems to be more so than [in] Southern California, at least at this point.

Chris Kresser:  Is there any reason for that?

Ramzi Asfour:  Probably the, I’m not so sure why the Seattle area has been more affected. But, certainly, there are lots of travelers from affected areas, especially from China, [who] commute back and forth to the West Coast. And I don’t know what the situation is in Vancouver, British Columbia, where there’s obviously also a very large Chinese community. That would be interesting to look at. But, definitely, in Seattle, San Francisco Bay Area, there’s a lot of travel to and from China. Silicon Valley’s here.

Chris Kresser:  Right. I mean, the West Coast makes sense for that perspective. But it’s unclear to me why LA [Los Angeles] wouldn’t be included, just given that it’s just so huge and there’s a lot of travel to and from everywhere in LA, including Asia.

Ramzi Asfour:  Absolutely. I mean, it’s a bigger metropolitan area than the Bay Area.

Chris Kresser:  Yeah.

Ramzi Asfour:  So I’m not sure why that’s the case. One can speculate a lot of things. We really don’t know enough about the virus yet. So take what I’m saying with that in mind, that we don’t have full knowledge. One, some people are postulating that warmer weather is a detriment to the spread of the virus, as it is for influenza, because droplets are one way, respiratory droplets. So when you’re speaking, for example, especially though when you’re coughing or sneezing, there’s lots of fluid droplets that you release into the air. And depending on who you talk to, those can spread between three and six feet.

So some people say stay three feet away. Some people say stay six feet away. But those droplets in warmer weather, they evaporate more quickly. The spread is probably less. That’s one of the reasons that we think that seasonal influenza, for example, is not as prominent in the summer as it is during winter and fall, for example.

Testing for the Coronavirus

Chris Kresser:  So I know we’ve talked about this a little bit offline. And you suspect that the incidence of coronavirus infection is already significantly higher than we know about, simply because the testing is not widely available. So people who are around us who are coughing and maybe have signs of the flu, especially adults who are not necessarily particularly sick, may already be infected, but we have no way of knowing that.

Ramzi Asfour:  Absolutely. I think that’s one of the biggest concerns. So, to address that, let’s talk about testing a little bit. And so, unfortunately, I have a lot of faith in our CDC [Centers for Disease Control and Prevention], and I used to work at the [WHO]. I’m a big proponent of strong public health infrastructure. I think that’s very, very important overall. And, unfortunately, our investment in public health infrastructure at the county level, in the United States, it’s really at the county level, where the on the ground people are, but also at the state and national level, has been decreasing. And budget cuts. We haven’t been funding public health infrastructure as much as I think we should be. And that’s evident in the CDC’s response to testing.

So, for example, for SARS, or especially Ebola, the CDC wanted to run all the tests. And I think that’s fantastic. I think that’s the right thing to do. But we did know about the huge number and burden of tests in China. And most people, we should always plan for what’s a reasonable worst-case scenario, in my opinion, in these kinds of infections. I like to use the term reasonable worst-case scenario. So not an end-of-the-world scenario, but what’s a reasonable worst-case scenario. And that is that we have high levels of activity of this virus throughout the country or throughout much of the country. With a prevalence, eventually, we could see as many as several percent of our population being infected, perhaps more, perhaps less. But that would be a reasonable worst-case scenario.

So that means that we should have been implementing and ramping up testing capacity earlier on than we were. I don’t know the details of the fine people [who] work at the CDC. I have a lot of respect, and I have a lot of friends [who] work at the CDC. So I don’t know what the details are behind the testing. But the good news is that the FDA [U.S. Food and Drug Administration] cleared the way to let people use what we generally call in-house testing kits. So those can be private laboratories and university laboratories that are able to develop their own kits, test them, and then just release them with a communication with the FDA, without full formal FDA review, which can take years. So, also, the Germans developed a kit that was adopted by the WHO. And it’s unclear why the CDC didn’t just say, “Well, let’s just use that kit.” They were able to ramp up production.

But, regardless, the testing issue is now being resolved. By the end of this week, we should be able to test maybe even a million people in this country. That would be fantastic. That will give us a sense of how many people have been infected already, and what we need to do, how we need to cohort. Cohorting means grouping people according to infection status. So if there’s a whole family that’s been infected, do we send them, if there’s a, for example, a school, what do you do? Do you, maybe there are five kids that are infected; do you quarantine their whole families? Do you, how do you handle all of that situation? I advise, in one of my roles, I advise nursing homes and hospitals on how to manage this type of situation infection. We call this infection control and infection prevention.

And [in] nursing homes, as we saw with the nursing home near Seattle, that’s an elderly population. They’re at very high risk. We are already advocating limiting visitation possibly and limiting group activities within the nursing home. The risk to the nursing homes is probably from visitors or staff that have traveled or gotten sick in the community. Right now, the CDC is requiring, they were initially requiring you to have traveled to China and be sick in an ICU to be tested. They’ve reduced [those] criteria. Now you can travel to one of those five countries that I mentioned earlier or be critically ill in an ICU. We still today don’t have enough testing kits to test many more people. But we will, hopefully, at the end of the week and by next week, be able to test quite a few people more and get a better sense of what’s going on. But I’m advising even my friends and family, I would not travel unnecessarily.

If you have an important meeting to go to, especially if it’s in a smaller group setting, that’s reasonable. But travel does have some risk. The risk is probably going to get higher for the next few weeks at least. And at that point, we’ll know a lot more. But people, we’re not advising completely eliminating airplane travel. We’re not advising completely eliminating social activities, but we need to be thinking about it. Planning for school closures, planning for cancellation of sporting events, for example. I’m not a huge sports fan, but somebody offered me tickets to go see the Warriors. I might say, “No.”

Chris Kresser:  I’m going to pass on that this time, yeah.

Ramzi Asfour:  I’ll pass this time.

Worried about the coronavirus? Check out this episode of RHR for more on what it is, the risks involved with it, and tips on protecting yourself against infection. #chriskresser #functionalmedicine

How Infectious Is the Coronavirus?

Chris Kresser:  Yeah. So let’s come back to that because I want to talk and help our listeners think through some of these questions about prevention and how concerned they need to be. And I think the answer to that also varies depending on their age and their health status, and where they live and some other factors. So I want to dive into that a little more deeply.

But before we do that, I think it would be helpful to compare what we know currently about coronavirus in terms of its R0 value. How infectious it is compared to something like seasonal influenza, which people are more familiar with and can use as kind of a benchmark? And then, what are the risks relative to something like seasonal flu with coronavirus for different populations? Because I think part of the panic is coming from, at least with some people I talked to, not really understanding the risk of what it means to get infected with coronavirus.

Ramzi Asfour:  Right. Thanks, that’s a great point. So the risk of infectiousness is probably about as bad as a bad flu, perhaps a little bit more. We don’t really know. Epidemiologists call that the R naught value or R zero. And that means how many people are likely to be infected from one person who’s carrying the virus or who is infected. And for seasonal influenza, it’s about 1.3 people are infected for every person [who] has the flu. And, initially, we thought the R0 for coronavirus was higher. It appears to be about 2.2 right now, but it might actually be lower. It’s difficult to say because, initially, the reporting from China was spotty and there was concern with testing capacity of some of the issues we’ve already discussed.

And then the second biggest outbreak was on the Diamond Princess, the cruise ship, and that was not a very well-managed situation in terms of spreading infection there. So it seemed more infectious, perhaps, than it would be in the community. So, for example, though, this is a very bad flu season. On top of having coronavirus, this season is a bad flu season. And I’ve been reinforcing recommendations to get vaccinated for the flu for several reasons. Think about the statistics. There are so far this flu season 310,000 hospitalizations for influenza and 18,000 deaths. So let’s just think about how many ventilators [are used for] those people who have [the] flu that could potentially be preventable and is treatable. We have drugs for [the] flu. If we were able, if the flu vaccine is only 50 percent effective, and this year, we think the vaccine might be 15 percent, sorry, 50 percent effective, somewhere in that ballpark, then you could cut those hospitalizations or deaths in half, at least of the patients who have not been vaccinated. And I don’t have those statistics broken down, who’s been vaccinated and who’s not. But we also know that people who are vaccinated tend to have less severe illness.

So, especially in a bad flu season, but also in a season where we need to protect our precious hospital resources, and so this is a public health issue. Your listeners might not know, but hospitals have been downsizing for a couple of decades now. Every time they build a new hospital, like in San Francisco, California Pacific Medical Center, they built a very nice new hospital, but there are fewer beds. And the same is happening all over the country.

Newer hospitals tend to have fewer beds than their older counterparts that they’re built to replace. That’s for complicated reasons, but we don’t have the capacity to hospitalize lots of patients in intensive care units who might become sick with the flu. So with the coronavirus, and even in a bad flu season, our capacity is overwhelmed in some regions. So the flu is very bad, dangerous. Don’t forget that. It’s still, in this country right now, the more common cause to have a cough, fever, [and] body aches, that’s probably going to be [the] flu rather than coronavirus, even today.

Chris Kresser:  So I just did some quick math while you were talking. There are 32 million flu cases, [with] 18,000 deaths. That’s about a 0.56 percent mortality ratio.

Ramzi Asfour:  Yes.

Chris Kresser:  I know this is a moving target and initial estimates were as high as 2 percent for coronavirus, but have since been revised down to maybe 1.4 percent. And you have told me you suspect it may be lower because if we don’t know what the denominator is, we don’t know how many people are actually infected. We can’t really come up with good data about that. But what’s the best guess right now in terms of mortality ratio?

Ramzi Asfour:  It’s difficult to say, but my suspicion is it’s probably, it’ll probably settle around 1 percent or maybe even a little bit less. We really need to know what the denominator is. And we need to know how many younger people who tend to have milder illness or even those symptoms, we need to know how many of them have been infected. And we might not learn that for several months. One of the ways to learn that would be to just do antibody tests on people’s blood to see.

What’s the Risk for Different Populations?

Ramzi Asfour:  You can do an antibody test, for example, to see if you’ve ever had [mononucleosis]. So we can do an antibody test to see if you’ve ever had COVID-19. We can’t do that today. But we will be able to do that test soon. And so, that will give us the denominator that we’ll need to really answer that question. But the illness seems to be very mild in children, younger people, [and] young adults. I’m definitely concerned that I believe Dr. Li, the 34-year-old Chinese physician, died of the virus in Wuhan. So that’s concerning. But we don’t know what his, if he had any underlying medical issues. There are, the mortality seems to be quite high in elderly people, however.

And so, what you have to think about is, not only will you infect, like, if your family, if you have a young family, if they get infected, [it’s] probably not a big deal. It’s going to be like a bad cold or a mild flu. But if you have grandparents that you’re in contact with, and especially if they have emphysema or some other underlying lung or cardiac condition, they’re probably at higher risk, and that risk probably goes up quite a bit. So we’ve had four deaths of people in the nursing home and several more in the intensive care unit from that one nursing home. And I don’t know how many of those patients have been infected in the nursing home overall.

But it sounds like it’s much more serious in the elderly. So we have to think about that. So you might be, if you’re living, for example, with an elderly person who has some lung issues, then you might take more precautions. And you might say, “Well, I am not going to do that traveling because I’m going to be with Grandpa. And if Grandpa gets infected, it could be super serious.”

Chris Kresser:  Right.

Ramzi Asfour:  That’s a consideration to [keep] in mind.

Chris Kresser:  So what are you, a couple of follow-up questions on that. When you say elderly, are we using over 65 as the cutoff? Or what’s the age cutoff in the research where you see the mortality ratio start to increase significantly?

Ramzi Asfour:  I don’t have a firm handle on that. But it seems to be, it’s probably closer to 70 or 75 even.

Chris Kresser:  These days, 65 doesn’t, people would take offense if they’re 65 and you classify them as elderly these days.

Ramzi Asfour:  Exactly, 65 is the new 50.

Chris Kresser:  Yeah. So in the 70s, and of course, there’s individual variation there. Because if someone has taken really good care of themselves, and they’re in excellent health at 70, then we could probably assume that their immune system is functioning better than someone who’s in very poor health at 70 years old.

Ramzi Asfour:  Absolutely.

Chris Kresser:  Yeah. So this is also different than the flu. With influenza, [the] elderly are at greater risk, as they are with coronavirus. But it seems there’s a distinction here with children, whereas children are often at higher risk for influenza, but it doesn’t seem that that’s the case with coronavirus. Is that right?

Ramzi Asfour:  That’s correct. It does seem to be the case that children and the elderly and pregnant women tend to be affected by influenza to a higher degree. Do you guys remember, if your listeners remember the swine flu epidemic, what, about 10 years ago now, that also affected overweight people disproportionately with that particular flu as well as pregnant women and children? But we’re seeing a skew here that it’s not clear if pregnant women are higher risk. We don’t think so yet, which is great. But it’s definitely a one-sided skew toward the elderly being more severely affected.

How to Protect Yourself against Infection from the Coronavirus

Chris Kresser:  So, let’s see if there’s anything else we want to cover on epidemiology and risk. It looks like, I think we’ve touched on most of that. Let’s move on to talk a little bit about protection. What are the things that will make the biggest difference? You already touched on some of them in terms of avoiding unnecessary travel and staying away from larger groups. I have a few follow-up questions about that. And then we can talk about things like handwashing and hand sanitizer and maybe not shaking hands.

Ramzi Asfour:  Right.

Chris Kresser:  Things like that. And then I’ll go into some of the botanical and nutrient-based protection and treatment stuff.

Wear a Mask Only if You’re Sick

Ramzi Asfour:  Fantastic. Fantastic. So protection. So a lot of people are asking, should I wear a mask? And my answer is please, if you’re sick and coughing, and you have to be out, for example, going to a doctor’s office, that’s when you should wear a mask. But if you’re just walking in the community, don’t wear a mask. Save that; we call those masks and gowns and other devices, we call that personal protective equipment. We need to save the personal protective equipment for those who really need it and would really benefit from it. Most people don’t know how to wear masks appropriately. A simple surgical mask that you might buy at a drugstore is not that [protective].

If you have facial hair, it’s even less protective. And N95 masks people might have heard of or even N99, but we in healthcare generally think that N95 masks are sufficient; those need to be fitted and you have to be fit tested. There are certain ways to wear them to offer full protection. And I’m not recommending that people wear masks. I have a flight booked to LA later in the month. I’m not planning on wearing a mask. And I’m planning on flying. But the handwashing, it’s frequent handwashing, 20 seconds minimum when you wash your hands, and not touching your face. So humans touch their faces way too often.

Chris Kresser:  Twenty times an hour from what I’ve seen, at least on average.

Ramzi Asfour:  Right, yeah. I catch myself doing it.

Chris Kresser:  I do, too. And so, that leads to a follow-up question about the masks. I’ve seen some recommendations that a mask might be helpful only insofar as it would limit contact between our fingers and our mouth and our nose. What do you think about that idea?

Ramzi Asfour:  That’s true. That’s true, but I’m not sure of the science behind that because the mask irritates the face, right? You’re going to need to reposition it often.

Chris Kresser:  Right.

Ramzi Asfour:  So you’re going to be touching the mask quite often.

Chris Kresser:  Well, and if your fingers touch coronavirus, the coronavirus can survive on the surface of the mask. Right?

Ramzi Asfour:  Right.

Chris Kresser:  If you touch the mask.

Ramzi Asfour:  Exactly, and then you’re going to, it’s going to irritate your skin, [and] you’re going to massage the skin that’s irritated. It’s not going to help that much. It’s certainly not going to help at home.

Chris Kresser:  Yeah.

Ramzi Asfour:  The cases where a mask at home would be recommended are when you’re being quarantined, basically. And then, if you have to step out from your, let’s say, you’re quarantined in your bedroom, and there are other people in the household who are not sick, then you might wear a mask when you’re going to the kitchen to prepare your meal. But you’ll eat your meal maybe in your room.

I mean, this is a whole can of worms that we haven’t even figured out how to deal with to handle isolation at home in these cases. There are some protocols and procedures, and a lot of people are working on that. And we’ve done it for cases of tuberculosis before, so we do have some experience. But it is, it’s concerning, and that might be an area to wear a mask.

Chris Kresser:  Here’s another question along the same lines. What about latex or nitrile gloves if you’re out and about and touching surfaces, like shopping or getting gas or even traveling? When I think about that, it’s like, okay, well, unless you’re taking off the gloves frequently and putting on new ones, you have the same concerns about, can’t the virus just touch the glove and you touch your face with the glove and it’s the same as not wearing a glove?

Ramzi Asfour:  Exactly.

Chris Kresser:  What’s the difference there?

Ramzi Asfour:  Exactly, yes. I wouldn’t recommend that. I would not. I mean, if you’re going to travel, what, actually, my wife likes to do on an airplane is take some sanitizing wipes, and she likes to wipe the tray table and the hand rests and the areas that you might come into contact with on the plane. That makes some sense. You’re disrupting any droplets, any virus that’s there, and significantly reducing your chance of coming into contact with it. That would make sense.

Chris Kresser:  So, yeah, I was just going to ask you about cleaning surfaces, sanitizing surfaces that you’re in contact with, like at home, for example. Should people consider a more OCD [obsessive-compulsive disorder], perhaps, cleaning routine than they would normally do at home with surfaces that they’re frequently coming in contact with?

Clean Surfaces You Come in Regular Contact With

Ramzi Asfour:  I would say extra cleanliness is warranted, or just bring up the level. Bring up your level of cleanliness to where you really want to see it at baseline. Don’t be too OCD about it, especially if nobody’s sick at home. But I wouldn’t go over the top. I don’t think it’s necessary. But I would just recommend clean[ing] bathrooms and sinks and faucets and taps, perhaps a little bit more than you would normally.

Chris Kresser:  I would also add computer keyboards. I remember I read somewhere, I don’t know about the science behind this, that they can be dirtier than a toilet seat in terms of germs.

Ramzi Asfour:  Absolutely. I occasionally work in hospitals, and the one thing that drives me nuts is I have to touch, and being an infectious disease doctor, I have to touch the communal workstations. The keyboards that all the nursing staff and other doctors have access to and everybody’s been touching the same keyboard. And I’m sorry, you just can’t perfectly clean a keyboard; it’s not possible.

Chris Kresser:  Yeah. So it seems like a risk there, but maybe at home using some alcohol-based spray would at least be helpful.

Ramzi Asfour:  Yes.

Chris Kresser:  Let’s go back to handwashing because we kind of flew over that, and I really want to emphasize the importance of this. Most of what I’ve read, and I think you agree, suggests that adequate handwashing, and I want to emphasize that, is probably one of the most important steps you can take to prevent yourself from acquiring this virus. But we also know, there was a study, I actually wrote an email about it recently. Let’s see if I can find it. That showed that, these researchers spent time in 10 airports, 10 of the highest traffic airports around the world. And they said only about 20 percent of people in those airports had clean hands, meaning they’d wash[ed] with soap for at least 15 seconds in the last hour.

Only 70 percent of people wash their hands at all after using the toilet in the airport. And of those who did wash, only 50 percent of those, so 35 percent total of people after using the toilet, washed their hands correctly using both water and soap and washing for at least 15 seconds. And I have to tell you, I’m a little bit of an observer of this phenomenon. Like, when I go into public bathrooms, I see people come out of a stall, and they head over the sink, and they just turn on the water, put their hands under the water for literally, like, two seconds, shake their hands out, and walk out of the bathroom. And I just cringe because it’s, like, I know too much, you know?

So let’s talk a little bit about the best way to wash hands with soap so that people really, this really sinks in. Because I think that the researchers in this study estimated using some modeling, that if we increase the rate, the number of people who have clean hands at the airport from 20 percent to just 60 percent, not even 100 percent, to 60 percent, that could reduce the global spread of disease by 70 percent. Which is just a huge, huge impact, like, more than just about anything we could imagine. So how should people be washing their hands?

Wash Your Hands Thoroughly and Frequently

Ramzi Asfour:  Yeah, that’s a great question because most people don’t do it properly. So, and this is from the CDC, okay? And this is what we recommend people do. So wet your hands with clean running water, warm or cold, and then you can turn off the tap and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. If you need a timer, the CDC’s recommendation, they say you can hum the Happy Birthday song from beginning to end twice. Okay? That’s way longer than most people think about washing their hands. Then rinse your hands under clean running water. And then dry your hands using a clean towel or air-dry them.

And the towel thing is what drives me nuts. In lots of developing countries, they have a towel at a public handwashing station. I would never use a towel that other people have used in the public area. At home, it might be different, but you might want to make sure that you’re washing your towels, or you have lots of small washcloths and you just launder them routinely instead of using that same towel over and over again.

Chris Kresser:  So a couple of follow-ups on this; I’ve read that a clean paper towel might be better than, like, the hand air-dryers because they might be more effective at removing spores. This wouldn’t apply to viruses per se, but other potential infectious agents like Clostridium or something like that.

Ramzi Asfour:  Right.

Chris Kresser:  Have you seen any evidence that supports that?

Ramzi Asfour:  There are quite a few studies showing that it’s the friction that’s most important. Whether you’re using alcohol jelly or washing your hands, it’s friction that’s very important. And the reason that, spores are not very well, like, for example, Clostridium difficile, spores are not well-removed by alcohol jelly because people, probably because people don’t use enough friction. They don’t do the rubbing or scrubbing for 20 seconds with alcohol jelly.

Chris Kresser:  Right. And I’ve heard that, I also read a study suggesting that alcohol hand sanitizer wipes were preferable to the jelly for that reason, because it adds more of that friction element. Although that seems to be somewhat controversial. I’ve read mixed reports on that.

Ramzi Asfour:  I mean, it makes sense that friction at the additional step of a paper towel on your hands would improve and would give you more friction and reduce any remaining infectious agents on your hands. It makes sense. In an epidemic, we are more likely to use disposable items. I’m also always considerate of the environmental impact, too, as you are.

Chris Kresser:  Yes.

Ramzi Asfour:  So we need to keep that in mind. Where usually, in a public situation, the air-dryers are sufficient. It’s really if you give yourself that 20 seconds of friction while you’re washing your hands, that’s probably enough. You also don’t want overfilled garbage cans with dirty paper towels all over the place. That’s a risk by itself.

Chris Kresser:  Okay, so here’s another pet peeve of mine or [a] thing that I often notice in bathrooms. So you wash your hands; you do it correctly for 20 seconds after you lather. You’re already way ahead of the game here, right? But then you go and you exit the bathroom, and you grab the handle of the door with your bare hand.

Ramzi Asfour:  I know.

Chris Kresser:  What’s wrong with this picture? So now, you’ve completely negated the benefit of washing your hands. And so, some bathrooms seem to be better set up. They have a paper towel dispenser near the door or close to where you wash your hands, and then they purposely put the trash can near the door, knowing that you should be using a clean paper towel to open the door when you exit the bathroom and then deposit that in the trash can right next to the door. So I just wanted to point that out because I don’t want people to go through all the trouble of washing their hands properly and then hold the door with their hand as they’re leaving, their bare hand.

Ramzi Asfour:  That is a pet peeve of mine, as well. And well said.

Chris Kresser:  So, definitely, people, make sure that you’re doing this. I think a clean paper towel is preferable to using your own clothing. Because if your own clothing has been, if you’ve come into contact with somewhere or someone who’s sneezed or coughed on your clothing, it’s better to use a paper towel than your own clothing to open the door. But I would prefer to use my own clothing than my bare hand, which I’ll sometimes do if I’ve been in a bathroom, for example, where there are no paper towels. Because that can happen.

So, along the same lines, we’ve been talking about handwashing, using the proper technique there and exiting bathrooms properly. What if you don’t have access to soap and water? We mentioned hand sanitizer earlier. So let’s talk a little bit about that. And I have to say, at least as of the time of this recording, there is no hand sanitizer available anywhere, at least from what I have noticed. So that’s a little bit of a concern. I know some of my patients and other people have expressed concern about that. They’re trying to get hand sanitizer, but they’re not able to get it. But let’s first talk about how to use it, when to use it, and then we can talk about that.

Use Hand Sanitizer

Ramzi Asfour:  Okay, so you have to worry about the quantity that you’re using. So, usually, the product will have the quantity you should use. And then you apply the gel to the palm of one hand. And then you rub your hands together. And you should do this for 20 seconds. That’s two Happy Birthday songs. Remember the friction that we were talking about. So it’s relatively simple to use. That’s an option. There are recipes online for making your own alcohol-based hand sanitizer that you can use. And I realize that there are shortages and that’s a problem. A lot of people are starting to hoard these types of things.

Chris Kresser:  Is there any way of making hand sanitizer at home that you know of that would fit the bill in terms of minimum alcohol content? And we should probably also mention that some of the next natural organic types of hand sanitizers, which admittedly, I tend to gravitate toward those products, are not effective if they don’t, at least they haven’t been proven to be effective if they don’t have alcohol content of at least 60 percent.

Ramzi Asfour:  Right. I think you need to have 60 or 80 percent alcohol. I’m not so sure. There are some recipes online, but you want to make sure that you have enough alcohol in there. You can use rubbing alcohol. Remember to keep that away from children. Rubbing alcohol can be a poison, [isopropyl] alcohol is a poison for humans if you take it internally. Externally, it’s fine. But you can, there’s lots of, I’m looking at one now that says mix aloe vera gel, glycerin, and rubbing alcohol in [a] small bowl, and you can flavor it, or scent it, with cinnamon.

Chris Kresser:  Essential oils. Yeah.

Ramzi Asfour:  Exactly.

Chris Kresser:  Yeah, I think doing that is probably better than nothing, even if you don’t get the percentage exactly right. And I would definitely err on the side of more alcohol than less, just to make sure you’re reaching that concentration. A few more other things for folks to think about, like maybe not shaking hands as much as you normally would, like a fist bump or an elbow bump instead. Or using things like your knuckle to touch light switches, or just being kind of, again, maybe a little bit more what some people would characterize as OCD in a normal environment with this kind of thing. What do you think about that?

Ramzi Asfour:  Think about elevators using, I use my elbow in hospital elevators to press the button.

Chris Kresser:  Right.

Ramzi Asfour:  Also, it’s hard not to shake hands. It’s really hard, and I struggle with this. But my preferred method is a, when you’re meeting new people, I like the Asian style or Japanese style. You put your hands just below your chin, almost in a prayer position, and you just, a slight bow of acknowledgment showing respect. And so, that makes the other person feel fine if they’ve offered their hand to you. So that you, you know, you’re showing them some respect. Thank you, but I don’t want to shake your hand. And they’ll realize, “Oh, good idea. I shouldn’t do it either.”

Chris Kresser:  Or you can make it fun, just a coronavirus fist bump.

Ramzi Asfour:  Right.

Chris Kresser:  Just like so it’s not personal.

Ramzi Asfour:  Exactly.

Chris Kresser:  And people will get it, and they’ll probably appreciate it, too. They might be feeling the same hesitation or nervousness about shaking hands. So, let’s shift over to talk a little bit about prevention. And I’ll sort of take the reins here, Ramzi, but I would love it if you’d chime in anytime.

Ramzi Asfour:  Okay.

Supporting Your Immune System to Prevent Infection

Chris Kresser:  And I want to start with just the basics, because I think we forget, we tend to forget the basics in situations like this. Really freak out or hoard the hand sanitizer and the gloves and all that stuff, and forget to just do the basic things. And, actually, one of those basics is stress management. We know that stress weakens the immune system as much [as] or more than just about anything. And there’s a little bit of a catch 22 here or a self-fulfilling prophecy. If people are totally freaked out and panicked about coronavirus, that’s actually going to impact their immune system in such a way that it would make them more susceptible to acquiring coronavirus.

Ramzi Asfour:  Absolutely.

Chris Kresser:  I really encourage people to do some things to try to, if you are feeling really worried and concerned, which is natural, it’s even more important to do things like a meditation practice, mindfulness-based stress reduction, spending time in nature, preferably not in large groups, but, you know, outside. Taking hot baths, whatever it is that helps you to manage your stress, that’s even more critical in this situation. So that’s one of the four pillars of immune boosting.

Another one is getting enough sleep. I’ve done so many podcasts on this [that], hopefully, I don’t need to go [into] any detail about why that’s important, or how to do it here. But seven to eight hours a night. And following all the good sleep hygiene practices. It’s critical for immune function. Physical activity is also really critical for immune function. So making sure to reduce your time spent sitting and then getting enough exercise throughout the week. And then the fourth pillar, of course, is a nutrient-dense, whole-foods, anti-inflammatory diet. But specifically within that context, really a focus on foods like liver, which is very high in vitamin A, which has many different immune-boosting benefits we’ll talk about shortly. Zinc, same thing for zinc, and many other nutrients that are a little harder to obtain, even in the context of a healthy diet.

Immune-Boosting Foods

Chris Kresser:  Foods like garlic and ginger, which have antimicrobial, antiviral effects and also immune-boosting benefits. You might want to increase your consumption of those. Citrus fruits and red peppers for vitamin C. Fermented foods, because we know that somewhere between 30 and 60 percent of the immune system, it really exists in the gut, so those can be helpful. And then a little bit of extra turmeric, if you like that as a spice, can be antiviral, anti-inflammatory, and can be helpful. You might want to consider some extra vitamin A, especially if you feel like you’re fighting something, [and] you come down with some symptoms. [Vitamin] A improves immune function by several mechanisms. It also increases lactobacilli in the gut, which, in the presence of infection, will produce interferons and other immune chemicals that fight infection. If you’re eating liver once or twice a week, you’re probably getting enough for maintenance. If you’re not, you might want to take cod liver oil, which is a great source of [vitamin] A as well as D, which is another important vitamin for immune function.

If you feel like you’re catching something, you can take very high doses of vitamin A for a short period. You don’t want to do that long-term, because vitamin A can be toxic at high doses. But 50,000 IU, for example, twice a day for up to five to seven days. You don’t want to take more than 100,000 IU at one time because it can cause headaches, and it’s a good idea to get enough vitamin D with your A because it can, it greatly protects against the toxicity, potential toxicity of vitamin A. Zinc lozenges support immune function and have also been proven to be effective in blocking coronavirus and other viruses from multiplying in the throat and nasopharynx. And you can use these several times a day as soon as you begin to feel symptoms. It’s best to lie down and let the lozenge dissolve in the back of your throat and the nasopharynx, so it really penetrates to those areas.

Honey and Other Bee Products

Chris Kresser:  So another preventative remedy, and something I will use for treatment, as well, that I like is propolis. Propolis is from the beehive, of course, and it increases cellular immune response and acts as an antiviral. My favorite way to take propolis is the Beekeeper’s Naturals propolis spray. It’s very convenient. You can spray it in the back of your throat several times a day at the first sign of symptoms. I will also use it prophylactically when I travel, even when I am not experiencing symptoms. And then another product from Beekeeper’s Naturals that I love for its immune-boosting and protective effects is called B.Powered, which is a honey, raw honey.

Honey is antimicrobial and antiviral, and it also has royal jelly, bee pollen, and propolis in it. So I will often take that if I feel like I’m coming down with something. You can just eat it right off the spoon. Kids love it. It’s probably the cold and flu medicine you’ll have the least trouble getting your kids to eat and that you might take yourself. And I have a relationship with the Beekeeper’s Naturals folks, so you can actually get 15 percent off if you go to Kresser.co/beekeepers of the propolis spray and the B.Powered.


Chris Kresser:  In addition to that, there are some botanicals that really help to support immune function. Cordyceps is one. It boosts immune function, protects cilia of the lung, modulates cytokine response, and increases T-cell count. Cordyceps is actually technically not a botanical; it’s a parasitic fungus that lives on insect larvae. So now, you’ll probably never take it after hearing that. It’s a pretty vivid description, but it’s a remarkably effective medicinal. Angelica sinensis, which is known as dong quai in Chinese medicine, aka female ginseng, modulates the cytokine response and lowers TGF-beta [transforming growth factor-beta] levels, which can be high in a viral infection.

Rhodiola improves immune function and protects the lung cells from hypoxia, which is one of the major impacts that a coronavirus can have. Astragalus boosts immune function and lowers TGF-beta levels. These recommendations all come from Stephen Harrod Buhner who’s one of, I think, the most foremost herbalists in the world. And his recommendation is to create a formula with three parts Cordyceps to two parts Angelica, one part Rhodiola, and one part Astragalus. And then take one teaspoon of that three times a day for protection and one teaspoon six times a day if you’re feeling symptomatic. If you do feel like you have come down with something, whether it’s coronavirus or just a seasonal flu, I posted some articles a while back. We’ll put the links in the show notes, to some other recommendations. One is a fresh ginger tea.

Ginger is a potent antiviral that prevents adhesion of viruses to the upper respiratory mucosa. But you have to take a lot of it for it to be effective. So, in these articles, I have a recipe for making a very potent fresh ginger juice or tea. Use one to two pounds of ginger, which is a lot, and the easiest way to do it is to use a juicer. So you juice it. If you don’t have a juicer, you can grate it, but it will take a while. And then you put two to four ounces of that ginger juice in a mug with the juice of one half lemon, a large tablespoon of honey, which is also antiviral, and then one eighth of a teaspoon [of] cayenne pepper, and six ounces of hot water. And then you drink two to six cups of that a day, sipping slowly throughout the day. It does not taste good. I’m going to tell you right now. It’s pretty intense, but it can be remarkably effective.

And then, for antivirals, herbs if you already have become infected, there’s a formula in Chinese medicine called Shuang-Huang-Lian, which was found to help a lot in China with the previous SARS outbreak and it’s now being tested in clinical trials there for COVID-19. And it consists of Forsythia suspensa, which is lian qiao in Chinese medicine, [the] weeping forsythia plant. So you use two parts of that. It’s antiviral for the SARS group, including COVID-19. It blocks viral attachment, modulates cytokine response. Then Lonicera japonica, which is jin yin hua in Chinese medicine, Japanese honeysuckle. Use one part of that. It’s also a strong antiviral for COVID-19. And then Scutellaria baicalensis, which [is] huang qin or Chinese skullcap. You use one part of that. And that’s antiviral for COVID-19. It blocks viral attachment, it modulates cytokine response, and it protects the spleen and the lymph nodes. And the dosage for that is one teaspoon, three times a day. And it’s best to take that in combination with some of the immune-boosting herbs that I mentioned previously.

So I know that was a lot. If you’re struggling to write all this down, we have a transcript of the podcast. So you can go to ChrisKresser.com and click on that, and you’ll see the transcript, and we’ll actually write out the recipes, so that you don’t have to dig through the transcript. So that you can just scroll down and get those recipes. And Ramzi, anything else you want to add in terms of treatment? I think in terms of antiviral drugs, we don’t have anything that we really know about, know that will work for coronavirus at this point. And what about a vaccine for coronavirus?

Ramzi Asfour:  Companies are already on the way. I mean, just really quickly, Remdesivir is a drug produced by Gilead. They’re already starting a phase three clinical trial. They’re targeting 1,000 patients to be enrolled. There are smaller trials taking place in China and the [United States], as well. And the first patient in Seattle actually received that medication. There are, Regeneron, they’re the company that made the antibodies or some of the antibody treatments for Ebola, and they are already hard at work making them for COVID-19. And then there are lots of companies working on vaccines.

Vaccines are going to take a while, but, hopefully, we’ll have some treatments. And one of the ideas is that we want to contain the infection as much as possible. So that once it becomes even more widespread, we’ll have some treatments. So the reason to be super aggressive, one of the many reasons to be super aggressive in containment, is waiting for treatments to become available for those [who] need it.

Chris Kresser:  So for those of you who want to learn more about the science behind some of the botanical recommendations that I shared from Stephen Harrod Buhner, you can go to his website. It’s a wealth of information. It’s StephenHarrodBuhner, S-t-e-p-h-e-n-h-a-r-r-o-d-b-u-h-n-e-r.com. Click on [“Writings,” and then] “Articles,” and then click on, under the [“Medicine/Herbs/Healing”] section, there’s a link. Click on “coronavirus.” It was written on March 1st. It’s a 19-page monograph [that] goes into great detail on:

  • The characteristics of coronavirus
  • What’s needed
  • What kind of pathological effects it causes
  • What specific medicinal botanicals address those particular effects of coronavirus

And so, [it gives] you a little bit more of the understanding behind how some of these formulas are created and also additional recommendations for medicinals that I didn’t cover in this podcast just due to time constraints. So that, hopefully, will be a good resource for you. Okay, everybody. Thanks for listening; stay safe and healthy. Ramzi, thank you so much for sharing your wisdom and experience with us.

Ramzi Asfour:  You’re welcome.

Chris Kresser:  Where can people learn more about your work? And if they’re interested in seeing you as a patient, how do they do that?

Ramzi Asfour:  For patients, go to CCFmed.com. And they can learn more about becoming a patient of mine through California Center for Functional Medicine. And I also do some infection control and work for especially nursing facilities. That’s CapsidConsulting.com.

Chris Kresser:  And although we spent today talking about an infectious disease, coronavirus, and Ramzi has deep experience in treating infectious diseases, that’s not all that he does. He’s also a phenomenal Functional Medicine practitioner, and that is what he is primarily doing, of course, at CCFM. Although, of course, treating infections is one of the things that we do as Functional Medicine practitioners.

So, Ramzi, thank you again. And we’ll definitely have you back to do the part two of the gluten and Lyme disease connection show because I know we got a lot of feedback that that was particularly interesting to people and we still [have] some material to cover there.

Ramzi Asfour:  Thanks, Chris. Appreciate it.

Chris Kresser:  All right. Okay, everybody. Thanks again for listening. Send in your questions [about the] podcast [at] ChrisKresser.com/podcastquestion, and we’ll talk to you soon.

Three Recipes for Immune-Boosting Botanicals

1. Stephen Harrod Buhner’s Botanical Formula

For this formula, you’ll need to combine:

  • Three parts Cordyceps
  • Two parts Angelica sinensis
  • One part Rhodiola
  • One part Astragalus

Take one teaspoon of this formula three times per day for protection against infection. Take one teaspoon six times per day if you’re experiencing symptoms.

2. Fresh Ginger Tea

To create this tea, follow these steps:

  • Juice one to two pounds of ginger, and place juice in a jar and refrigerate.
  • Place two to four ounces of ginger juice in a mug with the juice of one-half lemon and a large tablespoon of honey.
  • Add one-eighth teaspoon of cayenne pepper and six ounces of hot water.

Drink two to six cups of this per day, sipping slowly throughout the day.

3. Shuang-Huang-Lian Antiviral Formula

For this formula, you’ll need to combine:

  • Two parts Forsythia suspensa (also known as lian qiao or weeping forsythia plant)
  • One part Lonicera japonica (also called jin yin hua or Japanese honeysuckle)
  • One part Scutellaria baicalensis (also known as huang qin or Chinese skullcap)

Take one teaspoon of this formula three times per day. It’s best to take it in combination with immune-boosting herbs.

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