Chinese Medical Journal 2011;124(18):2925-2933 2925

Original article
Natural herbal medicine Lianhuaqingwen capsule anti-influenza
A (H1N1) trial: a randomized, double blind, positive controlled
clinical trial
DUAN Zhong-ping, JIA Zhen-hua, ZHANG Jian, LIU Shuang, CHEN Yu, LIANG Lian-chun, ZHANG Chang-qing,
ZHANG Zong, SUN Yan, ZHANG Shu-qin, WANG Yong-yan and WU Yi-ling

Keywords: influenza A (H1N1); Lianhuaqingwen capsule; clinical randomized controlled trial

Background The 2009 influenza A (H1N1) virus infection is associated with the high risk of severe complications and is
spreading more rapidly throughout the world than other reported seasonal influenzas. This study aimed to evaluate the
efficacy and safety of the nature herbal medicine Lianhuaqingwen capsule (LHC) in patients infected with influenza A
(H1N1) virus.
Methods A total of 244 patients aged 16–65 years confirmed with influenza A (H1N1) virus infection by the real time
RT-PCR were randomized to one of two treatment groups of 122 patients each. Each group assigned to receive either LHC
or Oseltamivir for five days and observation for seven days. The patients were enrolled within 36 hours of illness onset if
they had an axillary temperature of ≥37.4ºC and with at least one of the following symptoms: nasal obstruction, runny nose,
cough, sore throat, fatigue, headache, myalgia, chills and sweating. The primary end point was the duration of illness.
Results Of 244 patients, 240 (98.36%) patients with a median age 21 years completed the study between October 24,
2009 and November 23, 2009. There were no significant overall differences between LHC treated and Oseltamivir
treated patients in the median duration of illness (LHC 69 hours vs. Oseltamivir 85 hours P >0.05) or the median duration
of viral shedding (LHC 103 hours vs. Oseltamivir 96 hours, P >0.05). However, it was worthwhile to note that LHC
significantly reduced the severity of illness and the duration of symptoms including fever, cough, sore throat, and fatigue
(P <0.05). Both study medications were well tolerated. No drug related serious adverse events occurred during the study.
Conclusions Compared with Oseltamivir, LHC achieved a similar therapeutic effectiveness reduction of the duration of
illness and duration of viral shedding. Therefore, LHC might be an alternative therapeutic measure for influenza A (H1N1)
virus infections. (Clinical trial number: ChiCTR-TRC-00000589)
Chin Med J 2011;124(18):2925-2933

I n March 2009, the first case infected with 2009

pandemic influenza A (H1N1) virus was identified in
Mexico, this novel influenza virus spread-rapidly around
the world.1-3 Due to being highly contagious and wide
spreading, it is more lethal and has already caused social
disruption.4,5 According to the most recent report from the
WHO, as of 13 December 2009, more than 208 countries
and overseas territories or communities have reported
laboratory confirmed cases of pandemic influenza H1N1
2009, including at least 10 582 deaths.6 Facing a novel
virus, vaccination is considered to be the most effective
approach, nevertheless we usually encounter two difficult
problems, undersupply and/or oversupply,7-9 intensifying
the pressure on healthcare services.
Oseltamivir phosphate (Oseltamivir) and Zanamivir,
inhibitors of neuraminidase, have been recognized as the
most effective treatments presently available.10 But there
are limitations to such antiviral drugs: a low clinical
response in the patients if the initial administration of
Oseltamivir is 48 hours after the onset of illness,11 viral
resistance in some patients,12-14 the shortage of drug
supply and the comparatively high cost in some under-
developed countries.7-8 Therefore, there is an urgent need
to explore new approaches and drugs for disease control.15
DOI: 10.3760/cma.j.issn.0366-6999.2011.18.024
Beijing You-An Hospital, Capital Medical University, Beijing
100069, China (Duan ZP, Liu S, Chen Y and Liang LC)
Key Research Centre of Collateral Disease of State Administration
of Traditional Chinese Medicine, Yiling Pharmaceutical Research
Academy of Hebei Province, Shijiazhuang, Hebei 050035, China
(Jia ZH, Zhang J and Wu YL)
Kaifeng Infectious Disease Hospital, Kaifeng, Henan 475001,
China (Zhang CQ)
Jinan Infectious Disease Hospital, Jinan, Shandong 250021, China
(Zhang Z)
Henan Provincial Infectious Disease Hospital, Zhengzhou, Henan
450005, China (Sun Y)
Jilin Provincial Hepatopathy Hospital, Changchun, Jilin 130061,
China (Zhang SQ)
China Academy of Chinese Medical Sciences, Beijing 100700,
China (Wang YY)
Correspondence to: WU Yi-ling, Key Research Centre of
Collateral Disease of State Administration of Traditional Chinese
Medicine, Yiling Pharmaceutical Research Academy of Hebei
Province, Shijiazhuang, Hebei 050035, China (Tel: 86-311-
85901718. Fax: 86-311-85901088. Email: jiatcm@ 163.com); Dr.
WANG Yong-yan, China Academy of Chinese Medical Sciences,
Beijing 100700, China (Tel: 86-10-64032670. Email: wang4816@
yahoo.com.cn)
DUAN Zhong-ping and JIA Zhen-hua contributed equally to this
study.
This study was supported by a grant from the State Administration
of Traditional Chinese Medicine of the People’s Republic of China
(No. 200907001-5001).
2926
Alternative therapies, including nature herbal medicines
(NHMs) have been recommended as a practice measure
to treat influenza A (H1N1) in some countries and regions
of the world.16 For example, traditional therapies have
been used in China for treatment of infectious diseases
for thousands of years.17 Because of the fundamental
theoretical differences between traditional medicine and
modern medicine, and also due to the therapeutic effects
usually coming from the synergistic action of certain
ingredients of NHMs, it is more difficult to evaluate
NHMs efficacy and safety. The role of NHMs in
treatment is still controversial. Lianhuaqingwen capsule
(LHC), a kind of NHM, approved by the China State
Food and Drug Administration (SFDA) in 2004, has been
recommended as one of the drugs to treat influenza A
(H1N1) by the China health authority in 2009.16 Before
this study, there were several experiments that showed the
anti-influenza A action of LHC. For example, an in vitro
study showed that the treatment index of LHC
anti-influenza A with three drug delivery options,
including pre-treatment, co-treatment and post-treatment,
were higher than Oseltamivir phosphate. Another in vivo
study showed that LHC could provide protection to
Balb/C mice infected by influenza A virus, and the
survival rate and survival time of the LHC group were
prior to model group. In September 2009, influenza A
broke out in Langfang city of Hebei province. A
randomized controlled clinic trial showed that there were
no significant differences between LHC treated and
Oseltamivir treated patients in the duration of viral
shedding. However, LHC significantly reduced the
duration of symptoms including fever, cough, and so on.18
To further confirm its therapeutic effects, we conducted a
randomized, double blind, and positive controlled clinical
trial to evaluate the efficacy and safety of LHC in patients
infected with 2009 influenza A.
METHODS
Patients
Patients had to meet all the following criteria for
inclusion: with confirmed influenza A virus infection by
real time RT-PCR (rRT-PCR), age between 16–65 years
old, axillary temperature ≥37.4ºC and with at least one of
the following symptoms, cough, sore throat, headache,
running nose, fatigue, nasal obstruction, myalgia, chills
and sweating. Illness onset had to be within 36 hours,
women must be urine pregnant test negative and must use
effective contraceptive methods during the study and
within 30 days after the end of the study, and informed
consent was obtained.
Patients were excluded from the study if they met any one
of the following conditions: age younger than 16 or older
than 65 years old, axillary temperature lower than 37.4ºC,
those with underling primary disorders, such as
cardiovascular disease, cerebral vascular disease, hepatic
disease, renal disease, hematological disease or
psychological disorders, those with accompanying
pharyngitis, acute chronic obstructive laryngitis or acute
Chin Med J 2011;124(18):2925-2933
tracheitis, or brochures and pulmonary disease, lung
cancer, bronchiectasis or with concomitant respiratory
diseases, allergy to the study medication(s), those already
vaccinated or who will receive influenza vaccine, women
who are pregnant or may possibly become pregnant or are
lactating with a positive urine pregnant test, obesity (a
body mass index (BMI) of 40 kg/m2 or more), have
participated in other clinical trial within one month before
study randomization, and other reasons not suitable for
enrollment based on the investigator’s discretion.
The study protocol was approved by the central ethics
committee and the local ethics committee. An informed
consent was signed by each subject before the screening.
Study design
A multi-center, double blind, parallel and randomized
study was conducted in eight hospitals crossing seven
provinces in mainland China, with LHC as the
investigational medication and Oseltamivir as the positive
control. The randomization number for each site and
study medication was developed using a computer
random number generator with software SAS9.13. Each
block contained four numbers.
Subjects were randomly enrolled either in LHC or
Oseltamivir group in a 1:1 ratio; each subject was
assigned a randomization number in ascending order and
treated with the correspondingly identified study
medication until the enrolled subjects in each site reached
the scheduled number. Each block comprised four
subjects randomly assigned to either LHC or Oseltamivir.
Each site was scheduled to enroll no less than eight
subjects (two blocks) and no more than 56 subjects (14
blocks); based on the actual recruitment, the sponsor
adjusted them timely.
The nasal swab from each suspected case of influenza A
infection was first screened by the One Step Influenza
Virus A Paper Test (manufactured by Guangzhou WondFo
Biotech. Co., Ltd., China). The pharyngeal or
nasopharyngeal swab from patients with positive results
by paper test were collected and tested by rRT-PCR
(Beijing KINGHAWK Pharmaceutical Company, China)
to confirm the infection of influenza A (H1N1) virus. If
patients were positive for both tests and met the
inclusion/exclusion criteria, the subject would be
randomly assigned to either the LHC or Oseltamivir
group for administration study medications for five days
and observation for seven days.
Although the on site paper test only took about 15–20
minutes to get results, laboratory diagnosis by rRT-PCR
usually took about 6 hours, or even 12 hours in some
cases. To ensure subjects received the study medication
within 36 hours of the onset of illness and to improve
patient compliance, the study procedure was adjusted:
patients positive for the paper test who met the
inclusion/exclusion criterion were eligible to enter the
study and randomly assigned to either LHC or
Chinese Medical Journal 2011;124(18):2925-2933
Oseltamivir. Later on, if rRT-PCR tested negative, the
study medication was stopped immediately and the
patient was considered as not fulfilling the inclusion/
exclusion criteria and withdrawn from the study.
Rationale for sample size
The study was powered as a non-inferiority study, and the
primary endpoint was relief time of influenza-like
symptoms. Non-inferiority boundary value was 24 hours.
Sample size was based on a common standard deviation
of both groups was 60 hours, with an error probability of
0.025 (single-tailed alpha error) and 0.9 for beta,
computation formula described following yielded a
sample size of 107 subjects per treatment arm.
Considering a possible 20% expulsion rate, the designed
sample size should be 256 128 subjects per treatment
arm.
Study medications
Patients in LHC group received four capsules (0.35 g of
ingredients/capsule) of LHC/TID and one capsule of
Oseltamivir analogue/BIO orally for five days. Patients in
Oseltamivir group received one capsule (75 mg) of
Oseltamivir/BIO and four capsules of LHC analogue/TID
orally for five days.
All the study medications (LHC, LHC analogue and
Oseltamivir analogue) were prepared in identical-
appearing capsules (including color, weight and smell) by
the sponsor. Oseltamivir was manufactured by Shanghai
Roche Pharmaceutical Company. The personnel involved
in the manufacture and package were not allowed to have
any contact to the study subjects and the relevant study
personnel.
Detection of influenza A (H1N1) virus
Collection of nasal swabs and the One Step Influenza
Virus A Detection kit
The nasal swab was inserted in the nasal cavity having
lots of secretions, gently turned and pushed it to the
turbinate with the distance about 2.5 cm from the nostril.
After turning three times, take the nasal swab out then
follow the instruction of the test. The result was obtained
in 15–20 minutes.
Collection of swab of pharyngeal and influenza A (H1N1)
virus nucleic acid detection
The swab was taken out from the tissue culture tube, then
gently and quickly wiping the double transpalatal arch,
pharynx and tonsils. Sterilizing the test tube was
performed by heating under an alcohol lamp. Take the
swab and insert it into the test tube and plug the hole with
the cork. On the tube note the patient information and
patient’s number and date. Put the swab of the pharyngeal
into a sterilized solution and keep at −65ºC. Transport the
specimen to the virology laboratory of the local CDC or
virology laboratory of the local site in container with coal
pack within 12 hours of collection and assayed by
rRT-PCR.
2927
Data collection and follow-up
Clinical laboratory tests included routine blood tests,
urine tests, hepatic function, renal function, serum
myocardial enzymes and blood chemistry examination.
Physical examination, vital signs, chest X-ray, 12-head
electrocardiograph (ECG) and laboratory tests were
measured at baseline and the last follow-up or the day
when patient’s influenza-like symptoms were completely
resolved and laboratory test negative by rRT-PCR.
Patients’ specimens were collected and assayed daily by
rRT-PCR. Patients with any presenting symptoms were
evaluated by themselves based on the predefined four
levels of severity (0 absent, 1 mild, 2 moderate, 3 severe)
and axillary temperature was measured every six hours
with the maximum interval less than one hour and
recorded in the patients’ diary once daily.
Investigators collected and assessed the adverse events
and assessed any complications or any concomitant
medications including acetaminophen and antibiotics on
daily basis. At the last follow-up, patients returned all
medication containers and the remaining pills were
counted. If any symptom was not resolved, recording
continued until all the symptoms were resolved and
sustained for 24 hours.
Clinical outcomes
The primary end point was the duration of illness which
was defined as the time from onset of symptoms to the
alleviation of the nine influenza-like symptoms including
nasal obstruction, running nose, cough, sore throat,
headache, fatigue, myalgia, chills and sweating.19,20
The secondary end points included: viral shedding
duration, defined as the time from the illness onset to the
first time the viral nucleic acid test was negative; the time
to defervescence, defined as the time from the first dose
of study medication to the time when the body
temperature declined to lower than 37.3ºC and was
sustained for at least 24 hours; the severity of the disease,
assessed by an area under the curve (AUC) analysis of a
total of eight influenza-like symptom scores, the AUC
was calculated as the product of the daily symptom scores
times the duration of illness;20 time to individual
symptom alleviation, defined as the time from the onset
of the individual symptom to the time the symptom was
alleviated. Accuracy of measurement was one hour.
Safety evaluation
The safety population included all the subjects who
received at least one dose of study medication and for
whom post-baseline safety data were available. Safety
evaluations included adverse events and clinical
laboratory examination.
Statistical analysis
The clinical trial was analyzed by the principle of
intention to treat (ITT). ITT included all the subjects who
were randomly assigned to one of the group and received
2928
Figure 1. Study work flow chat.
at least one dose of study medication and for whom one
follow-up efficacy data point was available. We used the
last-observation-carried-forward method in the analysis
of all outcomes among patients who made at least one
follow-up visit but who did not complete follow-up. The
safety population included all the subjects who received
at least one dose of study medication and for whom
post-baseline safety data were available. The Cochran
Mantel-Haenszel (CMH) chi-square test or Fisher’s exact
test was used to analyze the difference in qualitative
parameters between groups. Two-group t test or paired t
test was used to compare the quantitative parameters of
normal distribution for two-group; and Wilcoxon rank
sum test was used to compare the quantitative parameters
of non-normal distribution. For statistical comparison of
the difference in time to relief of all flu-like symptoms
between the two treatment groups, a non-parametric
approach was chosen: the Hodges-Lehmann estimator
and the one-sided 97.5% CI according to Moses.21
Non-inferiority was concluded if the lower boundary of
the 97.5% CI was greater than 24 hours, as the difference
of 24 hours was considered as the clinically relevant
margin. Significant difference was established when P
values <0.05. All analyses were performed using SAS
software, version 9.1.3 (SAS Institute, USA).
RESULTS
Patient characteristics
From October 24, 2009 to November 23, 2009, a total of
405 suspected influenza A (H1N1) virus infected subjects
were screened by nasal swabs, 362 were found influenza
A positive by paper test. Of them 256 subjects that met
Chin Med J 2011;124(18):2925-2933
the inclusion/exclusion criteria and were randomly
assigned to treatment. Ten subjects, including five from
each group, failed the laboratory test. One subject from
the LHC group was administrated other NHMs after entry
into the study and the pharyngeal swab from one subject
in the Oseltamivir group did not detect virus by rRT-PCR
due to inappropriate transportation. The study medication
administration was stopped immediately for those 12
patients and they withdrew from the study. Final numbers
were 244 subjects, with 122 in each group included in
ITT analysis, with one from the LHC group and three
subjects from the Oseltamivir group lost to follow-up
(Figure 1).
The proportion of patients quarantined in a designated
dormitory of a college campus, in the hospitals and at
home was 54.5% (133/244), 31.1% (76/244) and 14.3%
(35/244), respectively. All the patients were instructed by
study investigators to measure their body temperature, to
score and record the severity of symptoms, and to
administrate study medications by themselves. All the
measurements were performed based on the standard
operating procedure attached to the patient’s diary card
and recorded on the patient’s card once daily. Of the
patients who were not hospitalized, the study investigator
visited those patients in the designated dormitory or at
home once daily to collect the records of the severity of
symptom scores and the patient’s specimens.
There were no significant differences between the groups
at the baseline in demographic variables including
duration of illness, body temperature before the initial
dose and physical examination, laboratory test (except
Chinese Medical Journal 2011;124(18):2925-2933 2929

Table 1. Demographic characteristics of the patients

at the baseline
Variables LHC (n=122) Oseltamivir (n=122)
Sex (M/F, n) 64/58 63/59
Age (years) 21.5±5.9 21.4±3.9
Vocation (n (%))
Student 103 (84.4) 106 (86.9)
Others 19 (15.6) 16 (13.1)
Co-existing disease (n (%)) 4 (3.3) 3 (2.5)
Combined medication (n (%)) 2 (1.6) 4 (3.3)
Temperature (˚C) 38.3±0.5 38.2±0.6
Body temperature (n (%))
≤38˚C 54 (44.3) 55 (45.1)
>38˚C and ≤39˚C 57 (46.7) 57 (46.7)
>39˚C and ≤40˚C 11 (9.0) 10 (8.2) Figure 3. Duration from onset to the first negative of H1N1
Respiration (beat/min) 20.2±2.4 20.1±2.0 virus by rRT-PCR.
Resting heart rate (beat/min) 87.6±11.6 86.0±10.9
Course of disease (hours) 19.6±8.5 19.5±8.2
the control group. The one-side 97.5% CI for the median
Body mass index (kg/m2) 21.2±2.4 21.2±2.7
difference in time to relief of flu-like symptoms between
groups was (−11; ∞) and the lower boundary was still
Table 2. Distribution of the patients
LHC Oseltamivir
higher than the non-inferiority margin (−24 hours).
Centre* Subjects Subjects
ITT PP SS ITT PP SS
enrolled enrolled Analyzing the total clinical response, as shown in Figure
1 26 26 26 26 26 25 23 26 2, the two Kaplan-Meier curves were completely
2 22 22 22 22 22 22 21 22 overlapped within the first 12 hours after enrollment, but
3 20 20 20 20 20 20 20 20
were split thereafter and remained parallel until the end of
4 12 12 12 12 12 12 12 12
5 20 15 14 20 20 15 15 20 the observation. This indicates better relief in LHC
6 4 4 4 4 4 4 4 4 treated patients, although there was no statistically
7 6 6 6 6 6 6 6 6 significant difference (median 69 vs. 85, P >0.05).
8 18 17 17 18 18 18 18 18
*Number of hospitals participating in this clinical trial. When it came to the alleviation of the severity of illness,
a significant difference was observed between the groups
(P=0.047). The areas under the curve were 281.2 for LHC
treated patients and 318.5 for Oseltamivir treated patients.
This indicated that in comparison with Oseltamivir, LHC
significantly reduced the severity of illness and the
duration of illness.

To eliminate any potential effects of analgesics and

Figure 2. Alleviation time of all symptoms in influenza A
(H1N1)-infected.
lymphocyte counts), chest X-ray film and ECG. The
baseline data and distribution for subjects were
comparable (Tables 1 and 2).
Time to symptom alleviation
The Hodges-Lehmann estimator for the median
difference in time to relief of all flu-like symptoms
between treatment groups was 10 hours and the one-sided
97.5% CI according to Moses was (2; ∞) (ITT
population). Considering that the non-inferiority margin
was set at −24 hours, the lower boundary of the CI was
clearly higher. A sensitivity analysis was also performed
for 18 subjects in the ITT population with non-remission
at the end of the study or who withdrew from the study.
In the sensitivity ananlysis,22 168 hours was assigned to
missing values in the LHC group and 0 hour to those of
antipyretics on the duration of illness, patients who
administrated analgesics and antipyretics during
observation were excluded, 15 from the LHC and 19 from
the Oseltamiviri groups. Still no significant difference
was observed in the median duration of the illness
between LHC and Oseltamiviri groups (68 hours vs. 83
hours, respectively; P >0.05). But Log-rank examination
demonstrated that LHC had a significant effect on the
reduction of the average duration of illness ((73±37)
hours for LCH vs. (86±35) hours for Oseltamivir,
P=0.0354).
Duration of viral shedding
The average duration of viral shedding in LHC treated
patients and Oseltamivir treated patients was (108±36)
hours and (101±34) hours, respectively, and Log-rank test
showed no statistically significant difference was
observed (P=0.1546). As shown in Figure 3, from 72
hours after illness onset to the end of the observation
period, the two Kaplan-Meier curves were completely
overlapped with each other. This confirms that from three
days of illness onset, no significant difference in viral
shedding was observed between the groups.
2930 Chin Med J 2011;124(18):2925-2933

Time to defervescence applied immediately at home, and the event was resolved
The average time to defervescence for LHC treated on day 18. The causal relationship with Oseltamivir was
patients was (17±14) hours (n=122) and (23±17) hours assessed to be unrelated and the event assessed as a
(n=122) for Oseltamivir treated patients, a significantly serious adverse event by the study investigator. The
improved defervescence effect for LHC (P=0.0059). reporting of serious adverse events was in accordance to
the relevant regulation of China health authority. There
To eliminate any potential effect of analgesics and was no significant difference in the incidence rate
antipyretics on the time to defervescence patients between the LHC and Oseltamivir groups. No study
administrated analgesics and antipyretics during medication was discontinued due to adverse events in the
observation were excluded, 15 from the LHC group and study. There were no adverse events judged to be related
19 from the Oseltamivir group. LHC had a significant to LHC, while there were four adverse events, nausea and
effect on reduction of the average time to defervescence vomiting, judged to be related to Oseltamivir.
over Oseltamivir (n=107, (15±12) hours for LHC
DISCUSSION
treatment vs. n=105, (19±15) hours for the Oseltamivir
group). Although vaccination and antiviral medicines,
Oseltamivir and Zanamivir, are the most effective
Based on body temperature, these patients were measures, certain limitation still exists for the control of
subgrouped into a ≤38ºC group and a >38ºC group. We the pandemic outbreak of novel influenza.23-26 Researches
found no significant difference in the average time to intent on finding more natural drugs against influenza A
defervescence between LHC treated patients (n=54) and have demonstrated in vitro or in mouse models the
Oseltamivir treated patients (n=55) in the ≤38ºC group anti-influenza virus activity of different plant extracts.
((12±13) hours and (15±14) hours, respectively, The known antiviral actions include causing virus
P=0.1770). Meanwhile, significant difference was inactivation, interference with viral replication, or
observed between the LHC (n=53, (17±10) hours) and blocking the spread of infection.27-30 LHC is a
Oseltamivir treated patients in the average time to combination of 45 ingredients extracted from 13 kinds
defervescence (n=50, (24±15) hours) in the >38ºC natural herbs including honeysuckle flower, isatis root,
subgroup (P=0.0077). weeping forsythia capsule, rhubarb, radix glycyrrhizae.
Although LHC has been used for treating seasonal
influenza in China since 2004, as an alternative therapy
Average duration of each individual influenza-like against influenza A (H1N1), its clinical effectiveness and
symptom safety evaluated by randomized clinical trial was largely
The average duration of each individual symptom was untested. We conducted the random, double blind and
shown in Table 3. Significant differences were observed Oseltamivir positive control study to evaluate its efficacy
in the average duration of symptoms like cough, sore and safety in patients infected with influenza A (H1N1).
throat, and fatigue (P <0.05). The above data clearly
showed that LHC had significantly greater effects on the The clinical features of influenza A (H1N1) are similar to
reduction of the average duration of the above symptoms. seasonal influenza: fever, cough, sore throat as the most
common symptoms, then headache, running nose, fatigue,
Table 3. The median disappear time (hour) and their 95% CIs of nasal obstruction, myagia and chills, nausea, vomiting
symptoms
and diarrhea seldom occur.8,31 A recent observational
LHC Oseltamivir
Symptoms
Case number Time (hours) Case number Time (hours)
study in Chinese patients showed that the most common
Nasal obstruction 66 47.0 (38.0,62.0) 62 43.0 (38.0,57.0) symptoms were fever, cough, and sore throat. The other
Running nose 71 27.0 (22.0,38.0) 71 38.0 (35.0,43.0) symptoms, like nausea, vomiting and diarrhea, were
Cough 106 62.0 (47.0,66.0) 104 73.0 (67.0,86.0)* comparatively uncommon.32 Accordingly these clinical
Sore throat 98 43.5 (39.0,47.0) 97 60.0 (47.0,64.0)* manifestations were regarded as the main symptoms in
Myalgia 56 20.5 (18.0,31.0) 60 36.50 (20.0,43.0)
the management guideline of influenza A (H1N1) issued
Fatigue 68 20.5 (17.0,23.0) 71 37.0 (24.0,42.0)*
Headache 77 22.0 (20.0,25.0) 76 34.50 (21.0,39.0)
by the China Health Authority.19 Influenza is a
Chill 57 19.0 (14.0,21.0) 53 18.0 (16.0,21.0) self-limiting disease, therefore, symptoms alleviation and
Sweating 29 19.0 (15.0,26.0) 30 21.0 (18.0,38.0) quality of life improvement are the goal of therapy. In the
*
P <0.05 compared with Oseltamivir group. present study, the most common symptoms in the study
population, except for fever (100%), were cough (86.1%),
Safety analysis sore throat (80.7%), headache (62.7%), running nose
There were no significant differences in the baseline data (57.8%), fatigue (57.0%), nasal obstruction (52.5%),
of laboratory test between the groups. There were a total myalgia (47.5%), chills (45.1%), and sweating (24.2%).
of 11 non-serious adverse events with four from the LHC Therefore, the relief of these symptoms was used to
group and seven from the Oseltamivir group, which were evaluate the clinical response.
assessed as possibly unrelated to medication. A patient
who was isolated at home developed pneumonia at study In the present study, 85.7% of patients were college
day seven, and antibiotics and supporting therapy were students with median age of 21 years old (16–65 years),
Chinese Medical Journal 2011;124(18):2925-2933
which reflects the demographic features of the second
outbreak of influenza A (H1N1) in China, and was similar
to previous reports from the United States.33 In
comparison with seasonal influenza, influenza A (H1N1)
was more likely to disproportionately infect individuals in
a younger age group.
This study demonstrated that no statistically significant
difference was observed in the median duration of illness.
Furthermore, no difference was observed between the two
groups, even after the patients who were administrated
analgesics and antipyretics medications excluded. It
seems worthwhile to notice that, in terms of AUC
analysis, LHC had a more significant effect on relieving
the severity of the disease. Meanwhile, we also noticed
that LHC had a significant effect on the relieving of
individual influenza-like symptoms like fever, cough,
sore throat, and fatigue.
The average time to defervescence for LHC treated
patients and Oseltamivir treated patients was 17 hours
and 23 hours, respectively. The six hour difference in
patients receiving LHC strongly suggested that LHC had
a better antifebrile effect than Oseltamivir. Further
stratified analysis failed to show any difference of the
time to defervescence in patients with body temperature
≤38ºC. However, we observed a significant difference in
LHC treated patients with body temperature >38ºC in
comparison to Oseltamivir treated patients, which again
indicated a better antifebrile effect of LHC. In terms of
the patients not administered analgesics and antipyretics
medications, the average duration of illness and the time
to alleviation of fever were comparatively shorter in LHC
treated patients than in Oseltamivir treated patients. This
indicated the effect of LHC was not affected by this
factor.
The previous studies found that, by tissues culture, the
highest percentage of active influenza A (H1N1) virus
existed within three days of the presenting of
influenza-like symptoms. The active virus in tissue
culture was even found in 24% of patients until the day
seven.34 A study conducted in China from April 2009 to
July 2009 found that the median illness duration (from
the onset of illness to the first time when the result of
rRT-PCR was negative) was six days (range, 1–17 days).
At the same time it also indicated that using of
Oseltamivir within 48 hours of the onset of illness will
reduce the duration of illness and viral shedding.31 In the
present study, the median viral shedding duration in LHC
treated patients and Oseltamivir treated patients was 108
hours, 101 hours, respectively. Accordingly,
administration of either LHC or Oseltamivir within 36
hours of the onset of illness produced a 25.2% or a
29.50% reduction in viral shedding duration compared
with the data in Cao’s32 reports. The accumulative
number of patients with viral nucleic acid clearance (test
negative by rRT-PCR) among the LHC treated patients
and Oseltamivir treated patients was 17.2% (21/122) and
2931
23.0% (28/122) on the third day of symptoms, which
grew to 81.2% (99/122), and 85.3% (104/122) on day 6.
In this study the intervention with either LHC or
Oseltamivir shortened the duration of the patients’ viral
shedding compared with the previous reports. This
indicated that both study drugs have similar therapeutic
effectiveness in inhibition of viral replication, with no
statistically significant difference observed.
In the present study, the duration of viral shedding from
79 patients, including 46 LHC treated patients and 33
Oseltamivir treated patients, was over five days. The
multivariable logistic-regression analysis under 0.05
examinations found the significance of association of risk
fact of sex and the prolonged duration of viral shedding at
the edge (P=0.053). No significant difference in the
grouping, body temperature, age, BMI, or the duration of
illness was observed. In consideration of the
characteristics of demography, like age and the time point
of administration, the present study results are consistent
with the previous reports.31
Oral LHC and Oseltamivir were well tolerated. No
difference was observed in laboratory safety evaluations
in the two groups. No drug-related serious adverse events
occurred in either group, neither of the study drugs were
discontinued due to adverse events. There was no-adverse
reaction in LHC treated patients, while there were four
adverse reactions in Oseltamivir treated patients, which
were nausea and vomiting. Overall, LHC and Oseltamivir
were well tolerated in the study.
Differently from other clinical trials of NHMs, the current
study was designed as a randomized, multicenter double
blind clinical trial conduced in China to evaluate the
efficacy and safety of NHMs in patients infected with
influenza A (H1N1). However, several potential
limitations of the present study should be considered.
First, since influenza A (H1N1) has the potential to
develop secondary severe complications, which are life
threatening and even lethal, a placebo group was not
considered. Second, the study protocol excluded the high
risk population and those patients with severe
complications. Third, the observation period was
comparatively short, the symptoms of six patients from
the LHC group and 12 patients from the Oseltamivir
group were not resolved completely on day seven and
their eventual outcomes were not included. Fourth, due to
the limitation of employing RT-PCR, the viral shedding
duration and the viral clearance rate were determined
qualitatively, and the dynamic change during viral
clearance could not be addressed in this study.
In summary, this randomized and double blind clinical
trial demonstrated for the first time LHC’s therapeutic
effect against influenza A (H1N1), the result showed that
LHC had a significant effect on the alleviation of fever,
cough, sore throat and fatigue. Regarding to the reduction
of illness duration and viral shedding duration, LHC can
2932
achieve at least the same therapeutic effectiveness like
Oseltamivir. Both drugs were well tolerated.
Acknowledgements: We thank Dr. ZHENG Qing-shan, LIU
Hong-xia and HUANG Zong-han (Shanghai University of
Traditional Chinese Medicine Clinical Research Center for Drugs)
for kindly guiding us through the protocol, data management, and
statistical work. We are also indicated to the patients for their
participation and investigators at the hospitals and local CDC for
data collection and laboratory testing.
We also thank the Clinical Investigation Group members for their
help in collecting samples: LI Xiu-hui, YAN Hui-ping, WU Hao
(Beijing You’an Hospital，Capital Medical University); SUN Yan,
HAO Yi-bin, MA Chao, WANG Yong-ming (Henan Provincial
Infectious Disease Hospital); CHEN Shi-jun, AN Yong (Jinan
Infectious Disease Hospital); WANG Li, DENG Ping, CUI Wen-yu
(Changchun Infectious Disease Hospital); ZHOU Ji-kun
(Shijiazhuang City Center Disease Prevention and Control); DAI
Er-hei, JIAO Xiu-kun, ZHOU Ting (Shijiazhuang Infectious
Disease Hospital); LIU Fu-qiang (Hunan Provincial Center Disease
Control and Prevention); WEN Xian-min, LI Ji-ke, ZHOU Xiao-fei
(Chengdu Infectious Disease Hospital); ZHANG Ming-xiang, YAN
Ying-chun (Shenyang Infectious Disease Hospital); BAI Wei, LI
Bao-fa, LIU Bao-hua, FU Min, YUAN Cui-yun, LI Shu-sen, CAI
Shang-yuan (Kaifeng Infectious Disease Hospital).
REFERENCES
1. DG statement following the meeting of the Emergency
Committee. Geneva: World Health Organization, 2009.
(Accessed June 11, 2009 at http://www.who.int/csr/disease
/swineflu/4th_meeting_ ihr/en/index.htm.)
2. Centers for Disease Control and Prevention (CDC). Swine
influenza A (H1N1) infection in two children, Southern
California, March–April 2009. MMWR Morb Mortal Wkly
Rep 2009; 58: 400-402.
3. Swine influenza update 5. Geneva: World Heath Organization,
2009. (Accessed December 18, 2009 at http://www.who.int/
csr/don/2009_04_29/en/index.html.)
4. WHO technical consultation on the severity of disease caused
by the new influenza A (H1N1) virus infections. Original
short summary posted May 6 2009. Revised full report posted
May 9 2009. Geneva: World Heath Organization, 2009.
(Accessed December 18, 2009 at http://www.who.int/csr/
resources/publications/swineflu/technical_consultation_2009
_05_06/en/index.html.)
5. Novel Swine-Origin Influenza A (H1N1) Virus Investigation
Team, Dawood FS, Jain S, Finelli L, Shaw MW, Lindstrom S,
et al. Emergence of a novel swine-origin influenza A (H1N1)
virus in humans. N Engl J Med 2009; 360: 2605-2615.
6. Pandemic (H1N1) 2009 update 79. Geneva: World Heath
Organization, 2009. (Accessed December 18, 2009 at
http://www.who.int/csr/don/2009_12_18a/en/index.html.)
7. Mossad SB. The resurgence of swine-origin influenza A
(H1N1). Cleve Clin J Med 2009; 76: 337-343.
8. Petrosillo N, Di Bella S, Drapeau CM, Grilli E. The novel
influenza A (H1N1) virus pandemic: an update. Ann Thorac
Med 2009; 4: 163-172.
9. France sells off surplus swine flu vaccine. BBC. One-minute
world news. January 3, 2010 (Accessed January 5, 2010 at
Chin Med J 2011;124(18):2925-2933
http://news.bbc.co.uk/2/hi/health/8438663.stm)
10. Centers for Disease Control and Prevention (CDC). Update:
drug susceptibility of swine-origin influenza A (H1N1)
viruses, April 2009. MMWR Morb Mortal Wkly Rep 2009;
58: 433-435.
11. Updated interim recommendations for the use of antiviral
medications in the treatment and prevention of influenza for
the 2009–2010 season. Atlanta: Centers for Disease Control
and Prevention, 2009. (Accessed December 18, 2009 at
http://www.cdc.gov/h1n1flu/recommendations.htm)
12. Lackenby A, Hungnes O, Dudman SG, Meijer A, Paget WJ,
Hay AJ, et al. Emergence of resistance to Oseltamivir among
influenza A (H1N1) viruses in Europe. Euro Surveill 2008;
13. Pii: 8026.
13. Centers for Disease Control and Prevention (CDC). Update
influenza activity — United States, September 28,
2008–January 31, 2009. MMWR Morb Mortal Wkly Rep
2009; 58: 115-119.
14. Centers for Disease Control and Prevention (CDC).
Oseltamivir-resistant novel influenza A (H1N1) virus
infection in two immunosuppressed patients, Seattle,
Washington, 2009. MMWR Morb Morta Wkly Rep 2009; 58:
893-896.
15. Wang YT, Chan CH, Su ZY, Chen CL. Homology modeling,
docking, and molecular dynamics reveals HR1039 as a potent
inhibitor of 2009 A (H1N1) influenza neuraminidase.
Biophys Chem 2010; 147: 74-80.
16. The guideline for the surveillance, reporting, diagnosis, and
treatment of pandemic (H1N1) 2009. Beijing: Ministry of
Health of the People’s Republic of China, 2009. (Accessed
December 18, 2009 at http://www.moh.gov.cn/publicfiles/
business/htmlfiles/mohyzs/s3585/200905/40478.htm.)
17. Hsu CH, Hwang KC, Chao CL, Chang SGN, Ho MS, Lin JG,
et al. An evaluation of the additive effect of natural herbal
medicine on SARS or SARS-like infectious diseases in 2003:
a randomized, double-blind, and controlled pilot study. Evid
Based Complement Alternat Med 2008; 5: 355-362.
18. Liu GX, Zhang YX, Yang JQ, Gao ZQ, Meng YC. The
randomized controlled study of Lianhuaqingwen capsule in
treating A/H1N1 influenza. Chin J Diffic Ccompl Dis (Chin)
2010; 1: 14-16.
19. The Guideline for the surveillance, reporting, diagnosis, and
treatment of pandemic (H1N1) 2009 (the third edition).
Beijing: Ministry of Health of the People’s Republic of China.
(Accessed October 13, 2009 at http://61.49.18.65/publicfiles/
business/htmlfiles/mohyzs/s3586/200910/43111.htm)
20. Treanor JJ, Hayden FG, Vrooman PS, Barbarash R, Bettis R,
Riff D, et al. Efficacy and safety of the oral neuraminidase
inhibitor Oseltamivir in treating acute influenza: a
randomized controlled trial. JAMA 2000; 283: 1016-1024.
21. Hollander M, Wolfe DA. Nonparametric statistical methods.
New York: John Wiley & Sons; 1973: 75-82.
22. Points to consider on missing data. EMEA: Committee for
Proprietary Medicinal Products, 2001. (Accessed September
20, 2009 at http://www.emea.eu.int/pdfs/human/ewp/
177699EN.pdf.)
23. Hayden F. Developing new antiviral agents for influenza
treatment: what does the future hold? Clin Infec Dis 2009; 48:
3-13.
24. Jefferson T, Di Pietrantonj C, Debalini MG, Rivetti A,
Chinese Medical Journal 2011;124(18):2925-2933 2933

Demicheli V. Inactivated influenza vaccines: methods,
policies, and politics. J Clin Epidemiol 2009; 62: 677-686.
25. Lackenby A, Thompson CI, Democratis J. The potential
impact of neuraminidase inhibitor resistant influenza. Curr
Opin Infect Dis 2008; 21: 626-638.
26. Cheng PK, Leung TW, Ho EC, Leung PC, Ng AY, Lai MY, et
al. Oseltamivir- and amantadine-resistant influenza viruses A
(H1N1). Emerg Infect Dis 2009; 15: 966-968.
27. Palamara AT, Nencioni L, Aquilano K, De Chiara G,
Hernandez L, Cozzolino F, et al. Inhibition of influenza virus
replication by resveratrol. J Infect Dis 2005; 191: 1719-1729.
28. Wang X, Jia W, Zhao A, Wang X. Anti-influenza agents from
plants and traditional Chinese medicine. Phytother Res 2006;
20: 335-341.
29. Ehrhardt C, Hrincius ER, Korte V, Mazur I, Droebner K,
Poetter A, et al. A polyphenol rich plant extract, CYSTUS052,
exerts anti influenza virus activity in cell culture without
toxic side effects or the tendency to induce viral resistance.
Antiviral Res 2007; 76: 38-47.
30. Droebner K, Ehrhardt C, Poetter A, Ludwig S, Planz O.
CYSTUS052, a polyphenol-rich plant extract, exerts
anti-influenza virus activity in mice. Antiviral Res 2007; 76:
1-10.
31. Human infection with new influenza A (H1N1) virus: clinical
observations from a school-associated outbreak in Kobe,
Japan, May 2009. Wkly Epidemiol Rec 2009; 84: 237-244.
32. Cao B, Li XW, Mao Y, Wang J, Lu HZ, Chen YS, et al.
Clinical features of the initial cases of 2009 pandemic
influenza A (H1N1) virus infection in China. N Engl J Med
2009; 361: 2507-2517.
33. Centers for Disease Control and Prevention (CDC).
Swine-origin influenza A (H1N1) virus infections in a school
— New York City, April 2009. MMWR Morb Mortal Wkly
Rep 2009; 58: 470-472.
34. Witkop CT, Duffy MR, Macias EA, Gibbons TF, Escobar JD,
Burwell KN, et al. Novel influenza A (H1N1) outbreak at the
US air force academy: epidemiology and viral shedding
duration. Am J Prev Med 2009; 38: 121-126.
(Received January 18, 2011)
Edited by SUN Jing

Correction
In the original article entitled Matrix metalloproteinase-9 was involved in the immuno-modulatory defect of
mesenchymal stem cell from chronic myeloid leukemia patients published in August 20 issue, 2011 (Chin Med J
2011;124(16):2423-2430), there are two errors in the author information: (1) the last author “LI You-bin” should be “LI
Wen-bin”; (2) the corresponding author is changed to be LI Wen-bin, Institute of Medical Oncology, Beijing Shijitan
Hospital, Captial Medical University, Beijing 100038, China (Tel: 86-10-63926351. Email: mountain.red@163.com)