Elderberry, COVID-19 and Cytokine Storm: Sorting Through The Science, Confusion And Fear

Let’s face it – we are all on high-alert. Since the announcement of the global Coronavirus pandemic and the declaration of a national state of emergency, we are all wondering what to do, how to protect ourselves and our families, and what to do if we get sick.

As a physician and an integrative health coach, I’ve been getting a lot of questions and concerns about the best ways to boost immunity, prevent infection, treat mild infections at home, and what the heck is the safest course of action.

In particular, recent fears and concerns have been raised about elderberry syrup, a very popular home remedy and immune booster, after a viral facebook post (no pun intended) this week warned “NO ELDERBERRY!” and went on to say “for the coronavirus, its best to AVOID elderberry at this time. I know that's counterintuitive for a respiratory issue, but let me explain why. As an immune stimulant, it can basically cause your lungs to damage themselves with this particular virus. The mechanism in question is a "cytokine storm" as referenced in the very credible The Lancet.”

So I thought it would be prudent to do a little of my own research into elderberry, its properties and mechanism of action, COVID-19, and cytokine storm. I’ve gone down a bit of a rabbit hole in search of the truth, and to the best of my abilities, given the current science (noting that I am not a virologist, immunologist, epidemiologist or herbalist) here is what I’ve learned and will share with all of you…

What is Elderberry?

Elderberry is a flowering plant native to Europe, praised widely over the centuries for its medicinal properties. The most common form, Sambucus nigra, is known for its characteristic bluish-purple berries. The bark, leaves and berries are actually poisonous if consumed raw, so elderberry MUST be cooked to be consumed safely. The white flowers, known as Elderflower, can be ingested raw and are often used to flavor waters or tonics.

What Makes Elderberry Medicinal?

What makes elderberries so special is that this tiny fruit is packed with antioxidants, including anthocyanins, bioflavinoids, phenols, as well as fiber and vitamin C. Why are antioxidants important? Well, they can neutralize free-radicals, which are waste products of cells that increase oxidative stress. Free-radicals can accumulate due to a wide range of stressors and insults from environmental causes, pollution, exposure to chemicals, inflammation and ischemia. When too many free-radicals build up, cells are damaged and inflammation results, causing things like heart disease, cancer, immune deficiencies, and many other acute and chronic illnesses. Antioxidants can come in and “scavenge” or clean up the mess left by cell damage from free-radicals. The body makes its own antioxidants, but the best source of antioxidants are fruits and vegetables, especially “superfoods” that contain high levels of these compounds. Elderberries would be in this category. Elderberry also has antiviral properties that may prevent or reduce the severity of certain common infections, like cold and flu.

What is Elderberry Used For?

Elderberry is most famous for its use as an immune booster in the prevention and treatment of colds and flu. And its not simply an old wives tale - there is some hard data to back it up (albeit small studies, noting that large-scale, randomized-controlled trials are very hard to come by in herbal medicine).

Here is some of the evidence in the literature for the use of elderberry:

In vitro, elderberry was shown to be effective against 10 strains of influenza virus.

In a study of 60 people with influenza A and B, those who took 15 ml of elderberry syrup four times per day showed symptom improvement in 2-4 days, while the control group took 7-8 days to improve.

A meta-analysis of randomized trials of 180 participants studying the effects of elderberry in cold and flu concluded that it is indeed effective in substantially reducing upper respiratory symptoms.

A randomized, double-blind placebo-controlled study of 312 air travelers taking capsules containing 300 mg of elderberry extract three times per day found that those who got sick experienced a shorter duration of illness and less severe symptoms than those taking placebo.

So, all of this sounds really good, right?

How Does Elderberry Work in Cold & Flu?

Elderberry’s antiviral activity on influenza is thought to be through a number of mechanisms of action, including suppressing the entry of the virus into the cell, modulating the post-infectious phase, and preventing viral transmission to other cells. While we don’t entirely understand how elderberry works in preventing or treating cold and flu, here are some studies and some theories:

1. It may prevent viruses from attaching by damaging the external virus envelope. This was seen in a study looking at the ability of elderberry to prevent infection by Coronavirus in chickens. Damaging the virus membrane rendered it non-infectious.

2. Polyphenols and flavonols can bind to viruses and prevent infection.

3. Lectins found in plants, like elderberry, can also prevent binding of viral proteins to host receptors, preventing their interaction and inhibiting infection.

4. Elderberry can increase the production of inflammatory cytokines in healthy individuals - in addition to its antiviral properties, elderberry extract and its formulations activate the healthy immune system by increasing inflammatory cytokine production (IL-1 beta, TNF-alpha, IL-6, IL-8)

What are Cytokines & Why are They Important?

So, what are cytokines anyway? Well, they are chemical messengers used to send signals between cells. They get released by one cell and can bind to receptors of a bunch of different cells causing various effects in the body, some inflammatory, some anti-inflammatory as well as other body and cellular functions. Cytokines are pretty complex, and don’t just have one function – their effects depend on when they are released, what other cytokines are released with them, what cells they bind to, etc…not a simple, straightforward system by any means.

Famous cytokines include Interferons (IFN), Interleukins (IL), chemokines, Colony Stimulating Factor (CSF) and Tumor Necrosis Factor (TNF). Some cytokines, like Interferons, have even been used in the treatment of diseases like rheumatoid arthritis and multiple sclerosis. Cytokines all have different complex functions from recruiting cells, proliferating cells, causing cells to activate and differentiate. While it’s all really intricate, one thing to note is that the immune response is a delicate balance between pro-inflammatory and anti-inflammatory cytokines.

When an injury occurs somewhere in the body, inflammation sets in – pain, redness, heat, swelling, loss of function – all hallmarks of acute inflammation, and it’s actually a good thing because it helps treat the injury by calling in help. Cells are recruited, blood flow increases, and cells come help out and repair the damage. This all works really well when it’s working properly, but when things go awry, when the inflammation is really severe, uncontrolled, and persistent, bad things can happen.

What is Cytokine Storm?

Cytokine Storm is a clinical syndrome that arises when inflammation is severe and ongoing causing tissue damage, multi-organ system failure, and even death. It can be caused by infection, autoimmune, and iatrogenic (certain drugs or treatments) causes. It results from a failure of negative feedback of the immune system (i.e. inflammation forgets how to turn off) and there may be certain diseases and genetic markers that predispose to this condition. Treatment of cytokine storm includes treating the underlying cause, supportive care, immune suppression, and possible suppression of various inflammatory cytokine families, like IL-1, IL-6 and TNF-alpha.

What is the Connection Between Coronavirus and Cytokine Storm?

Well, right now we are experiencing a global outbreak of a novel human coronavirus known as COVID-19. In most cases, the virus causes mild respiratory symptoms and may even go unnoticed in young, healthy individuals. However, in older or at-risk individuals, and rarely in young, healthy individuals, the consequences of coronavirus can be severe. These most commonly include debilitating pneumonia resulting in hospitalization, ICU stays and even death. In the most severely affected patients, the common denominator appears to be overwhelming infection, inappropriate excessive host response, severe inflammation and lung pathology (Acute Respiratory Distress Syndrome - ARDS), characterized by Cytokine Storm. In the recent Lancet article, the presence of elevated cytokine levels in these severely affected hospitalized patients with COVID-19 was reported as “ increased plasma concentrations of interleukins-2, -7, and -10, granulocyte-colony stimulating factor, interferon-γ-inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1 alpha, and tumour necrosis factor α.” Potential therapies are currently being investigated for treating COVID-19 and reducing mortality in these severe cases, including an IL-6 inhibitor monoclonal antibody, Tocilizumab.

What Does This Have To Do With Elderberry?

Good questions and one I have been asking myself…

Since elderberry is an immune stimulant and can raise levels of certain pro-inflammatory cytokines, and since Coronavirus in rare, extreme cases can cause an overwhelming immune response with elevated cytokines, the message is DO NOT TAKE ELDERBERRY. But that seems quite simplistic and overblown to me with lots of leaps in logic. Here’s why:

1. There are zero reported cases or associations of elderberry and cytokine storm.

2. The only data we have on elderberry and elevated cytokines are in healthy volunteers, meaning all we know is that as a preventive measure, it may work partly in this manner.

3. The cytokines elevated with elderberry are not the same cytokines elevated in cytokine storm in Coronavirus according to The Lancet. However, IL-6 was elevated in Chinese patients who died of Coronavirus in this letter to the editor.

4. Remember that elderberry also has all of these antioxidant properties that are ANTI-INFLAMMATORY? So it has many, many mechanisms of action, not just elevating cytokines.

What’s The Bottom Line?

Based on all of the evidence, I believe that elderberry is relatively safe and may be effective in preventing and shortening duration and severity of colds and flu. How it behaves in relation to Coronavirus is not completely known, but in one study in avian Coronavirus it was very effective in preventing infection.

I will continue to take elderberry as a preventative, probably 1 tsp of homemade syrup a day (this is a great recipe), which I am also giving to my kiddo (no evidence in kids, and also kids are not currently being affected by Coronavirus but can still transmit it, but I also like to avoid the flu! Many of the kids in her class have had it and she hasn’t). If I develop mild symptoms, I will probably still take elderberry. If my symptoms worsened or became more severe, I would probably stop taking it. While it’s a great supplement for mild symptoms, it is no substitute for the flu vaccine, Tamiflu (note: these are effective against Influenza, but not Coronavirus) or for hospital care if you are severely ill.

One exception to taking elderberry may be in cases where autoimmune disease is present with already high circulating levels of IL-6 and TNF-alpha, like rheumatoid arthritis, juvenile arthritis and psoriasis. Again, this has not been documented or studied, but check with your physician if you or your child has an autoimmune condition before using elderberry.

What Else Can I Do to Protect Myself And My Family?

1. Wash your hands – it cannot be restated enough, that this is your best defense against COVID-19. Soap, hot water, 20 seconds minimum, using good technique. If you can’t wash your hands, use hand sanitizer with a high concentration of alcohol (at least 60-70%). If you can’t find any, you can make your own! Here’s the recipe I used. And here’s a video of me and my kiddo making it!

2. Try not to touch your face. I know, it’s nearly impossible. Most people touch their faces 23 times an HOUR. Yikes. Especially for small kiddos, it’s definitely a challenge (she keeps loosening that tooth!). But do try. Viruses gain entry via your mucus membranes, eyes, nose, mouth!

3. If you are feeling even a little bit sick, stay home. Don’t go to work. Don’t socialize. Don’t go out. Avoid sick people as much as you can. Cough into your sleeve.

4. Practice Social Distancing – cancel group events, avoid large gatherings, telework, schools are canceled here so home schooling it is! Even if you and your family are not high risk, this is the BEST way to flatten the curve, avoid catastrophic spread of infection and overwhelming of our healthcare systems.

5. Drink Lots of Water – this is always good advice, but in these times, staying hydrated helps keep your body and your immune-fighting cells functioning optimally.

6. Eat Healthy Food – again, I always recommend this, but load up on vegetables, greens, fruit, fermented foods like sauerkraut, kombucha, miso and kimchi. Also avoid unhealthy foods – sugar, alcohol, processed foods – as these can damage your microbiome and immune response.

7. Consider a Few Supplements – I don’t usually take a ton of supplements, but here’s what I’m currently taking: Vitamin D3, Fish Oil, Probiotic. I’m also drinking a daily ACV tonic known as Fire Brew – it’s full of immune-boosting herbs, organic honey, garlic, horseradish, and other good stuff. Use the code WILDLILACWELLNESS to save 15%.

8. Spend Time Outside – fresh air, physical activity, natural vitamin D – all help fight infection and fight cabin fever!

9. Try to Stay Calm – I know, it’s easy for stress to take over right now. And it’s understandable to feel panicked. Try some deep breathing (I love the Dr. Andrew Weil 4-7-8 technique and practice it with all my clients), meditation (LOVE the Headspace app), or Yoga (try the Glo app to avoid going to group classes).

10. Follow Dr. Elisa Song, MD of Healthy Kids, Happy Kids. She’s a holistic pediatrician and full of incredible advice on Coronavirus and a whole lot of other things.

And those are my words of wisdom for today! If you enjoyed this article, please share it with your friends and networks. And to stay up to date on all things health and wellness and to get my FREE downloadable guide “5 Surprising Ways To Boost Your Energy” subscribe to my monthly newsletter. I’m also more than happy to answer any questions via email, or on Facebook. To book a free, private session with me, just schedule your appointment here! Stay safe, healthy, and Wild about Wellness!

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