Documentation of indigenous knowledge on medicinal plants used to manage common influenza and related symptoms in Luwero district , central Uganda

1 Department of Plant Sciences, Microbiology and Biotechnology, School of Biological Sciences, College of Natural Sciences P. O. Box 7062,Makerere University Kampala, Uganda. 2 Natural Chemotherapeutics Research Institute, P. O. Box 4864, Ministry of Health, Kampala, Uganda. 3 Traditional and Modern Health Practitioners Together Against AIDS (U), LTD, P. O. Box 21175, Kampala, Uganda. 4 Department of Chemistry, College of Natural Sciences P. O. Box 7062, Makerere University Kampala, Uganda.


INTRODUCTION
Influenza, commonly known as flu in Uganda, is a contagious respiratory infectious disease which is air borne and is widely spread especially in the hot windy temperatures (Hudson, 2009;Centre for Disease Control, 2016).For a long time, influenza has been a non-fatal disease in the Tropical African countries.However *Corresponding author.E-mail: katuurae@gmail.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License in the recent past; the disease has caused serious health concerns throughout the world, Tropical Africa being at the highest risk because of its devastating consequences on human and animal health (Qiao-Feng et al., 2012).Consequently, many Sub-Saharan African countries are likely to be at risk of influenza epidemic due to migration of Asian and European nationals for investments in the industrial and other sectors.Most importantly, it is necessary to take precaution and prepare for the influenza epidemic outbreak.As most countries in sub Saharan Africa continue to face challenges of HIV epidemic, patients have compromised immunities which put them at risk of influenza infection.The problem is aggravated by the change of diets from the nutritious half cooked or raw fruits and vegetables, staple boiled or steamed foods to fried and junk diets that have less immune stimulating properties and fewer minerals and vitamins that fight off various diseases including influenza.Although chemotherapy is the mainstay in the management of various diseases including influenza in Uganda, plants remain an important source of medicines especially for the rural poor.The use of plants in the treatment of various diseases has been embedded in many indigenous societies, leading scientists to depend on such plants for drug development.Among the various indigenous medicines used in the treatment of common diseases such as malaria are plants used in treatment of influenza.The use of plants as medicine has been attributed to the presence of bioactive components such as flavanoids, alkaloids, saponins and tannins (Evans, 2002;Farnsworth, 1994).Several studies have confirmed antiviral activities of medicinal plants (Rajbhandari et al., 2001;Gebre-Mariam et al., 2006;Qiao-feng et al., 2012).
Like other sub Saharan African countries, majority of the rural communities in Uganda use medicinal plants in the treatment of diseases including influenza.Considering the rate at which natural vegetation which are source of medicinal plants are being depleted due to increased population pressure on the land and climate change effects, many important medicinal plants are disappearing before they are even documented, leave alone being scientifically validated.Moreover, dyeing off of the old people who are the custodians of indigenous knowledge even worsens the situation.Because of poor conservation of indigenous knowledge, scientists have used ethno pharmacological survey as the main approach to search for important plant species that can be evaluated for development of efficacious drugs (Farnsworth, 1994).Although many of these ethno botanical surveys have been carried out in Uganda to document plants used in treatment of various diseases, no systematic study has particularly been carried out for documenting in depth information on medicinal plants used by communities in treatment of influenza and related ailments.In this study, we obtained indigenous peoples perception of the disease and documented the plants, parts used, mode of preparation and administration of medicinal plants and practices used by the local communities to treat influenza and related symptoms in Luwero District in Central Uganda.We also documented common formulae as used by the respondents in the surveyed areas.

Study area
An ethno botanical survey was conducted in Luwero district (Figure 1), central Uganda in the two sub counties of Luwero and Butuntumula.Luwero district was chosen because there are organized Village Health Team (VHTs) members and herbalists at the community centre for traditional medicine, supported by the Ministry of Health.The research team also has established good working relationship with the leaders and some respondents.Luwero District is also one of the districts of Uganda that had experienced the Ebola viral disease outbreak in the recent past (Figure 1).The survey was carried out between May and June, 2012 to document community perception of the influenza and related infections symptoms, forms, causes and plants used for its management by the indigenous communities and related infections.Information was collected using individual interviews with semi structured questionnaires, focus group discussions, key informants and direct observation in the field from consenting adults who included both males and females of 18-60 years of age.A total of 60 households that mainly comprised of a village health team representative who are members of the community selected by Ministry of Health, Uganda to Coordinate Health programme at village level (MoH, 2010) and a few Traditional Health Practitioners (THPs) were interviewed.Information on community perception of manifestation of influenza disease, plants and parts used in the treatment, their preparation and dosage was documented.Family heads/representatives that had at least two children below the age of five were selected using Snowball method (Hardon, 2001) and interviewed.This was because children below five are the most vulnerable to influenza infection (Mbonye, 2004).After the individual survey, focus group discussions (FGD), each consisting of 10 members (both females and males) was conducted at the community centre for traditional medicine located at the district.
The FGD was to document priority plant, methods and formulae used in the treatments of influenza related symptoms.In depth interviews with key informants that included two elderly and five renowned THPs in the area were carried out to obtain in depth knowledge on community perception of influenza manifestation and its management.In addition, Allopathic Health officials at national health facility (Kasana Government Health Center in Luwero District) were also interviewed in order to get in depth knowledge of influenza frequency of occurrence among patients and its management at the health centre.Field excursions were carried out to identify the plants reported by VHTs and THPs and voucher specimen were collected.Voucher specimens were identified by a taxonomist at Makerere University National Herbarium, Kampala and then deposited at the Natural Chemotherapeutic Research Institute, herbarium in, Kampala.

RESULTS
The results of socioeconomic demographic characteristics of the respondents in this study are presented in Table 1.Most of the respondents (88.9%) were aged between 18 years to 55 years and.Majority (70.0%) were female with 87% being married.Approximately 57.0% of respondents had family size of between 5-9 members.The education of most respondents indicated majority (56%) having completed primary level of education with most of the respondent (84.7%) being farmers as their main occupation.

Nomenclature of influenza in Luwero district
Respondents further categorized influenza disease and gave it names according to the differences observed in its manifestation.The different categories and the proportion of there occurrence are summarized in Figure 2. The common occurrence of the disease (86%) was the mild infection termed "Senyiga" (Luganda dialect) and was mainly associated with symptoms such as running nose, mild headache, sneezing and tears in eye, however the respondents said that the patient has no other complications.Patients manifesting with "Senyiga" rarely visit the health centre because the condition allows them to do their daily activities.The other common type of manifestation (52.3%) was "Lubyamira", described by respondents to be severe illness that impairs the person from work.The patients manifesting with Lubyamira are likely to be bed ridden for a while, and to have productive cough in association.While the third type of manifestation was referred to as "Yegu" and this had symptoms like "Lubyamira" but mainly affects the elderly.Unlike "Senyiga", the respondents reported similarity in the symptoms of "Yegu and "Lubyamira" the difference was age of the individual.Lukusense and Seseba were rare

Mode of transmission of common influenza
The community knowledge on mode of transmission of common influenza are presented in Table 3.The respondents gave a diversity of the possible causes of influenza.Most respondent (40.0%) identified wind as major cause of influenza while 20% reported that sometimes a person is vulnerable to get infected with influenza due to diseases such as asthma.About 15% reported that a virus is the cause of influenza, but 13.3% said it was taking un-boiled water, smoke (11.1%), lack of body fluids (6.7%), dust, aeroplanes and staying near already sick people, transmission by birds, coldness, and dry seasons were cited by 4.4 and 2.2% of the respondents respectively.

Infection according to age
According the respondents, infection with influenza is not segregate as presented in Figure 3. Nearly half of the respondents reported that influenza affect all age groups.Although, 44.4% reported that it affects mostly children, 17.8% reported that affects new born babies.Meanwhile 15.6% reported those elderly people were most affected by influenza while 8.9% reported that pregnant women were also commonly infected by influenza.

Frequency of infection with influenza
The number of times and individual could be infected by annually was given by respondents as presented in Figure 4. Twenty percent of respondents reported that a person is infected by influenza any time and every 3 month respectively.About 14% and 12% of respondents said it be weekly and monthly, respectively.Eleven percent of the respondents reported that the disease affects an individual in almost every four months.Four percent could not estimate the number of times a person could be infected by influenza annually.

Method used by communities to treat influenza
The respondents reported various methods used to manage influenza at household in community are presented in Figure 5.Most respondent (45.2%) reported using allopathic while 19% used herbal medicine.About 35.7% reported that they combined both herbal medicine and allopathic medicine.

Medicinal plants used in treatment of influenza
The medicinal plants used for treatment of influenza and related symptom are presented in

Information on percent availability, formulation and administration of herbal mecicines
The respondents gave information on the availability, formulation and administration of herbal medicine to treat influenza as presented in Table 5.

Habitats of the medicinal plants
The medicinal plants used for treatment of influenza and  related symptoms are still accessible to the households.Majority (54%) of the respondents reported to collect them from the wild while about 46% harvest them in backyard gardens.The respondents also said that majority (97%) of the plants are abundant and only about 3% were said to be rare.

Type of herbal formulation
Among the formulations, majority (55%) were reported to be formulated from single plants while 45% formulated from mixtures of plants that range from two to six in the respective formulae.In these formulations, the three most regularly used plant parts were; leaves (90.2%), followed by the stem bark (63.4%) and fruit (31.7%) in order of preferred use by respondents.Also used were the root bark (22.0%) bulb (7.3%) and whole plant (4.9%), as shown in Figure 6.A part from medicinal plants, other natural products reported to be added in some formulae include; egg york, ash, salt, cow ghee, milk, mushrooms, cold sponge and water.

Method of preparation and administration
The most common methods preparation of the herbal medicines reported by respondents included; decoction

DISCUSSION
Clinically, influenza disease in human is associated with symptoms such as; cough, malaise and fever and this is normally accompanied with sore throat, nasal obstruction and sputum production (Hudson, 2009).Nevertheless, in severe cases it causes bronchitis, pneumonia, asthma and chronic obstructive pulmonary disease (Morens et al, 2007).Children under five years and elderly are more vulnerable, because of their immunity is low (Bearden et al., 2012;Yu et al., 2013).Until the recent past in most tropical African countries, influenza as a disease has been considered a mild infection that clears without any/strong medication.In view of this, community knowledge perception of the influenza epidemic is important since community knowledge of influenza symptoms and it management can be used to develop strategies for its control.The fact that common influenza virus causes low immunity among patients could also lead to the patients getting secondary infections, particularly in manifestation described as "Lubyamira and Yegu" by the respondents in this study.While knowledge of influenza manifestation is important, understanding its management particularly in the rural settings is important too.For centuries, knowledge of medicinal plants in management of diseases has been a key to almost every community.In sub Saharan African countries like Uganda, herbal medicine is used by majority due to the poor infrastructure of the national health care system which leads to inaccessibility of allopathic drugs and also high cost for the available conventional health care.Herbs have also been proven efficacious against influenza and other viruses (Xiuying, et al., 2012;Mousa, 2015) and communities have strong belief in herbal medicine with high level of acceptability due to the perception that they  are efficacious and safe makes its use widely acceptable (WHO, 2003).The plants reported in this study have been reported in previous ethno botanical surveys , and a few of them have also been proven scientifically to possess immune boosting properties, antibacterial, antiflammatory, antiviral activities, vitamins and minerals.For example, Citrus fruits and Psidium guajava have bioactive compounds, vitamin C, and micro minerals that are good immune boosters (Gutierrez et al., 2008).In addition other ethno botanical studies have indicated plants in families Mytaceae, Rutaceae, Lamiaceae and Anacardiaceae to have been used in traditional medicine and to possess therapeutic properties (Koudouro et al., 2011).According to Menkovic et al., (2011), Nepeta cataria (Lamiaceae) is ethno botanically reported to treat cold and fevers associated with influenza.On the other hand there has been observed strong co-movements between influenza and Malaria in some tropical countries which suggest that humidity which is an important factor in transmitting malaria also plays a role in influenza transition (Vaisenberg and Noymer, 2011).This is coupled with the fact that Influenza has symptoms related to those of malaria.In fact the symptoms are not that dramatic and can easily be mistaken for an attack of influenza (Netcare, 2014).In the rural areas of Uganda, most people in the local communities take medicines including herbal medicines without diagnosis.It is possible that some of the cases that were reported to be influenza could be malaria cases.It is therefore probable that these herbal formulae used for treatment of influenza also have antimalarial activity.The team will in future validate antimalarial activities of these formulae to ascertain their efficaciousness.Unlike Allopathic medicine which has clear guidelines and is standardized the world over.Herbal medicine especially in most African countries including Uganda is not standardized at almost all stages of development and use.Majority of the measures documented in this study such as handful, pieces, leaves are not uniform and this brings about a major discrepancy in formulation and dosage.It is intended that these formulae will be standardized as well as be evaluated for their effectiveness if in addition to their safety and efficacy in treatment of influenza and related infections.

Conclusion
This study conducted in Luwero district in Central Uganda, identified and documented 29 medicinal plants and about six formulae used for treatment of influenza and related symptoms by the respondents.The Indigenous knowledge has been organized to support conventional measures in the management of influenza and related symptoms and the evaluation of the efficacy of priority medicinal plants/ herbal formula in vivo is ongoing.All together, the information obtained in the study will be used in the standardization of herbal medicine that can be recommended for used against respiratory infections at household level in Luwero.Phytohemical investigations are recommended to determine the active compounds in the plants.While clinical trials to determine the efficacy of the plant formula in human are suggested.There is high chance that an active molecule with antiviral or antibacterial inhibiting properties can be identified and used as a template in developing a cheaper and affective medicine that can be used in the management of influenza and related illnesses.Tested and efficacious formula in clinical trials can also be integrated in the national health care system for treatment of influenza and other bacterial infections at household level, particularly in the rural areas where access to allopathic medicine is still a challenge.
training in medical anthropological studies research capacity.

Figure 3 .
Figure 3. Age group affected by influenza in Luwero district.

Figure 4 .
Figure 4. Frequency of infection with influenza.

Figure 5 .
Figure 5. Method used by communities to treat influenza.

Figure 6 .
Figure 6.Parts of medicinal plant used for treatment of influenza and related symptoms.

Table 1 .
Socio-economic demographic characteristics of respondents.

Table 2 .
Knowledge of the respondents, on the symptoms of influenza in Luwero district.

Table 3 .
Community and traditional health practitioner's knowledge of possible causes of influenza.
Figure 2. Different local names of influenza in Luwero district.

Table 4 .
(McGaw et al.,2001;Eloff et al., 2008)s used, method of preparation and mode of administration for the treatment of influenza and related symptoms, in Luwero district.Combretum molle R. Br.ex G.Don f.EKM/97 (Combretaceae) Endagi O Decoction SB , Steaming SB 14.0 Biological activity(McGaw et al.,2001;Eloff et al., 2008) Key: Part of plant used: SB, Stem bark; L, Leaves; RB, Root bark; F, Fruit; WP, Whole plant; A, Arial part; Method of preparation: Decoction, boiling of the dry plant for some minutes and leaving to cool; Steam Bathing, Boiling of the herbs in water and covering to inhale steam; Juice is squeezing a liquid from the plant part; Infusion, bringing to boil; Chewing, eating of the plant part raw.Route of administration:O Oral; B Bathing; S steaming; M massaging.

Table 5 .
Presents percent availability, formulation and administration of herbal mecicines used by the respondents of Luwero