Sunday 28 June 2020

Covid-19 & Vitamin D : more information

The pandemic of Covid-19 is running its course and it is now approaching its end. We might be told by government spokespersons that "we are winning", but that is fantasy. What would have happened if we had lost? 

There will now be many trillions of Covid-19 virus copies and we cannot destroy them all. Similarly they cannot all mutate into a milder form simultaneously. To do so would not be an advantage for Covid-19 as it already has a low population mortality rate. It is a disadvantage for a parasite to kill its host as then it and subsequent generations will die. Talk of eradicating a virus is wrong  as viruses do not "go away". 

Pandemics come to and end because we either die or develop immunity: it is the disease that goes away, not the virus. The incidence of winter respiratory virus diseases declines when in April the intensity of the sun at 50 degrees north of the equator becomes adequate to produce vitamin D on exposed skin.

UK experience
It is interesting to look at what has happened in the UK. We have had a large number of cases and deaths from Covid-19 (309,360 cases, 4583 per million population).  What is meant by a "case" is not always clear. It could be a mild and brief upper respiratory tract infection or it could be life-threatening pneumonia that is survived. International statistics do not differentiate. Death is more definite, but there is still a dilemma. If an elderly person with an advanced chronic disease such as dementia contracts Covid-19 and dies, it is likely that Covid-19 will be recorded as the cause of death, but not always. It could be argued that Covid-19 is only about 10% responsible for death, and advanced dementia the remainder. If a young person is killed in a car crash and tests positive for Covid-19, I hope that road traffic accident would be the registered cause of death.

Cases per million world-wide

San Marino, and to a lesser extent Andorra, have had a bad time during the pandemic. We can see that they have had by far the largest number of cases per million. They are small states, with populations of 33,400 and 77,200 respectively. If we remove these two unusual and rather tragic "outliers", we can appreciate the larger nations.

Vatican City has had 12 cases of Covid-19. With a population of only 801 this works out at 14,981 cases per million. There have been no deaths.

Two months ago Luxembourg had by far the most cases per million, but several others have now caught up and the USA has surged ahead. A large number of cases is not always matched by a large number of deaths. Unfortunately it is in San Marino and Andorra.

Deaths per million world-wide

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The UK has at present the fourth highest number of Covid-19 deaths per million in Europe, perhaps in the world. San Marino still has the highest, with Belgium second. Andorra has a slightly higher number than the UK. We can also identify the few nations with more than 200 deaths per million population.

It is tempting to compare two countries to try to explain the differences in incidence or deaths. It has been attempted by many experts but they have given up. Comparing two countries cannot result in a meaningful conclusion. There are 215 nation states on the WorldoMeter web site but only one pattern does appear. This is a latitude effect, case severity rates increasing with distance from the equator. This is most notable in the northern hemisphere, and it is Europe that has seen the major impact of Covid-19.

Whatever we have done in the UK to prevent deaths can hardly be described as a great success. But there remains something that could have been of great benefit, but of which the government's medical-scientific advisors have remained ignorant or which they have negligently ignored. It is Vitamin D.

Messages from the Far East
The early observations from the Far East indicated a high death rate of people with very low vitamin D levels. We have seen three of these in previous posts, and now there are others from Singapore, Germany and the UK. once again they are "preliminary reports" that not have been "peer-reviewed". The objective is to provide rapid help for those who trying to deal with the pandemic, not to write a retrospective review.

This study assessed the severity of Covid-19 in an individual by whether there was a need for oxygen therapy. On admission 17 patients were given a combination of vitamin D, magnesium, and vitamin B12 (DMB). 26 patients acted as controls. 3 of the 17 given DMB turned out to requires oxygen, compared to 16 out of 26 in the control group. 2 of the DMB group required ITU admission compared to 16 in the control group. 

As a result of this short study, all patients subsequently admitted to hospital with Covid-19 in Singapore have received vitamin D, magnesium, and vitamin B12..

This studyundertaken in Saarland,  was retrospective and was not directly concerned with Covid-19. It had followed up for ten years 9,548 people aged 50–75 and assessed mortality patterns. Vitamin D deficiency was defined as less than 12ng/ml (30nmol/L), which is a level that will not lead to bone disease (rickets or osteomalacia). 

A blood level of 12 to 20ng/ml (30 to 50 nmol/L) was defined as vitamin D insufficiency. The studies from the Philippines and Indonesia used vitamin D 30ng/ml (75nmol/L) as threshold for ideal blood levels. Apart from the use of two measurements, the lack of a consensus of the ideal blood level of vitamin D means that studies are not always comparable.

First, it found that most of the people had inadequate levels of vitamin D. 15% had very low levels of vitamin D, less than 12ng/ml (30nmol/L). 44% had levels 12–20ng/ml (30–50 nmol/L). This in itself is alarming; very few will have had vitamin D levels greater than  30ng/ml (75nmol/L).

The result was a two-fold increase in mortality from respiratory disease in those deficient or insufficient in vitamin D, with blood levels less than 20ng/ml (50nmol/L. It is suggested that this should be relevant in the prevention of deaths from Covid-19, and that correction of widespread vitamin D deficiency / insufficiency should receive attention.

Newcastle upon Tyne, UK
A short observational study compared patients who were managed on a medical ward compared to those who had deteriorated to the extent that they required ITU care. Those requiring ITU care had lower blood levels of vitamin D, indicating that in at least one UK hospital blood levels of vitamin D were actually being measured. The ITU patients were also younger, but this might have been due to an admission policy.

The evidence increases in favour of a benefit from vitamin D in the prevention of serious and fatal Covid-19. There have been many observational studies that have all shown a similar benefit from vitamin D, and there have been no studies that have shown the opposite. There is no evidence of undesirable effects. On June 25th 2020, there have been 9,560.837 reported cases of Covid-19 and 485,622 deaths, We have not been made aware of a single case of ill-effect or death from vitamin D.

Whether or not to take or advise vitamin D requires judgement, a balance or risks, weighing possible benefit against possible danger. The possible benefit is "not dying". There is no danger. 

Is there a dilemma? No!

Further action and the "second wave"
The obvious way to stop a pandemic (the serious disease not the virus itself) is to optimise the immunity of the population. As explained earlier, this cannot be achieved by a vaccine as the time-scale is much too short, and it is not of course possible to develop the vaccine before the virus has emerged. Immunity is optimised by making certain that the immune system has available a good reservoir of vitamin D to enable escalation at the time of serious infection, for example Covid-19. 

Vitamin D cannot be synthesised
The point is that vitamin D is a vitamin, meaning that it is not possible for the body to synthesise it. The body can synthesise 7-dehydro-cholesterol (7-DHC) and this has been feature of animal life for more than 500 million years. It is an accident of evolution that UV light from the sun converts 7-DHC into vitamin D (Hormone-D if you prefer). This is a physico-chemical processes and not metabolism. The immune cells covert 25(OH)D (the circulating blood reservoir of vitamin D) into 1,25(OH)D, the active form but this can ahead only if there is adequate 25(OH)D in the blood. During a serious infection vitamin D as 1,25(OH)D is "consumed" and so the blood level will fall, but it will remain in the ideal range (>30ng/ml) as long as the blood level was good (about 40ng/ml) initially.

What is the ideal level of vitamin D?
This brings us to consider the controversial point as to  the "normal" blood level of vitamin D. Normal is a statistical concept, meaning what is found in about 90% of the healthy population. It is appropriate in a metabolically controlled substance in the blood, such as sodium (Na), but it is not appropriate in respect of vitamin D, which cannot be synthesised and which is not under metabolic control. 

It is appropriate to use the term "ideal" as the blood level of vitamin D (as 25(OH)D.

The Maasi people of east Africa are found where humankind originated and from where most have emigrated to lands distant from the equator. They live an outdoor life-style close to the equator, and have dark skins that protect them from the high energy UVB light to which the are exposed. The availability of industrial textiles today will improve protection from the intense sunlight.

It is interesting that the great apes have white skin, and this is protected from UV light by thick hair. It was when evolution progressed in East Africa to relatively hairless Homo Sapiens that a dark skin became an evolutionary advantage. The earlier Neanderthal man is thought to have had a pale skin, giving an advantage in emigration to Europe.

The Maasai people have an average blood vitamin D level slightly greater than 40ng/ml (100nmol/L). This is the safe and effective level that evolution and nature determined. We should accept this as the ideal, with observation that it gives a health advantage, for example Philippines, Indonesia, Singapore. 

Vitamin D deficiency 
Emigration, "civilisation", and religion have diminished exposure to the sun, but evolution has given an advantage to those with white skins when living far distant from the equator, especially in extreme north-west Europe. This was millennia ago, but during the 19th and 20th centuries there was a large migration from South Asia and Africa to Northern Europe and North America. It is clear that this transmigration has resulted in a poor health profile. Although initially there is inevitably social-economic disadvantage, vitamin D deficiency will also become inevitable. This is the main and the most easily reversed reason for the poor health profile of BAME people, clearly demonstrated in the Covid-19 pandemic

It is negligent that BAME people in the UK and other countries are generally not informed of their inevitable vitamin D deficiency. For reasons that are also negligent, blood testing for vitamin D are discouraged. However I tested blood vitamin D levels in 1,500 South Asian people and the results are in a previous post. Pregnant BAME women are often but always given vitamin D supplement.

Some ethnic Asian friends tell me that now knowing about the dangers of vitamin D deficiency and their susceptibility to it, they spend more time outdoors in the sun. This is commendable, but there remains the fact that melanin, the skin pigment, absorbs UV light and is an excellent sun-screen. It diminishes production of vitamin D.

To ensure a good supply of vitamin D as 25(OH)D in the blood,] (40nm/ml, 100nmol/L) it is usually necessary to take a supplement by mouth, about 3,000 units per day.

Coming very soon:

Sunday 7 June 2020

Covid-19 & Vitamin D – progress?

Lake Geneva, looking east
May 2020 was a strange month. At the beginning of the month the pandemic in Europe had reached its peak, and in many countries it virtually finished by the end on the month. The cumulative deaths had reached a plateau, as for example in Switzerland. Additional deaths from Covid-19 had virtually come to an end: the Swiss epidemic, among others, was effectively over.

It had been recognised early in the pandemic in the UK, USA and Sweden that people of black African and Asian ethnicity (BAME) were over-represented in critical care and fatal Covid-19 disease. This was automatically attributed to socio-economic disadvantage. However, at the end of March and during April the UK had experienced the deaths of 25 doctors from Covid-19, and 24 of these were of BAME. This was key finding, the vital anomaly or paradox, the observation that generates a new and powerful understanding.

The government accepted with some reluctance that excess BAME deaths were due to socio-economic disadvantage, and appointed committees to "look into it", kicking the can down the road. The inevitable long time-scale made it obvious that this approach had no hope of reducing BAME or other deaths during the pandemic. We just watched people die, about 500 per day. What a waste. What a tragedy.

The BAME groups within the UK similarly showed no sense of urgency. The agenda appeared to be automatic, that the cause of the excess deaths was "racism". The groups had an awareness of racism and socio-economic disadvantage, and general sociological issues. They would have had no knowledge of biological science. How sociological issues and racism could be solved during the timescale of the pandemic was a mystery, but again there was and still is no obvious imperative to actively prevent Covid-19 deaths. 

There is much evidence to indicate that Vitamin D deficiency is responsible for the high incidence of BAME Covid-19 deaths. It requires a knowledge of biological science and cytogenetics, but with that and other information it is just a matter of "joining the dots". 

In this way it is possible to obtain a clear picture that is not "racism".

But why were the government medical and scientific advisors unable to join the dots? And what about the medical journals and colleges? The published evidence was readily available.

The lack of a sense of urgency has been astounding. We were in the midst of a serious pandemic with many deaths, and we were well aware of what was happening. It was as though we were standing on a beach when we received a warning of an impending tsunami. Rather than immediately heading inland to high ground, we would appoint a committee!

BAME doctors are not socio-economically disadvantaged, nor do they live in overcrowded houses. They have a wide variety of ethnic origins with great deal of genetic diversity. But the thing that they have in common is inherited skin pigmentation. It is, or it should be, well-known that pigmented skin is very inefficient at producing vitamin D by the action of the sun. As a result BAME people have on average blood vitamin D levels only half that of the white population, and even they have levels that are lower than desirable. 

Everyone knows that vitamin D is something to do with bones and that deficiency leads to rickets in children. Very few people seem to know that vitamin D is essential for the escalation of immunity in response to serious infection. Some doctors must know this, especially those close to the Chief Medical Officer and the Chief Scientist. But from them, there has not been a whisper of what might have helped. They watch as the disaster unfolds. The Chief Scientist, Sir Patrick Vallance, stated at the end of April that we would do well if the number of deaths were less than 20,000. At more than 40,000 he must feel like a failure. but at least it is less than 500,000, the worst case predicted by Professor "Lockdown" Neil Ferguson!

I am know of many doctors and others who are aware of the potential of vitamin D to boost immunity at this vital time, and the frustrations that they have had in failing to bring this to national consciousness. The silence from this "at the top" is not easy to understand, when at this time of national emergency we might expect our leaders to seize an opportunity to control the illness and death resulting from the epidemic. 

We have seen early warnings sent from the Far East, from the Philippines and Indonesia, that described that someone with a blood vitamin D level greater than 30ng/ml (75nmol/L) will have about a 95% chance of survival from Covid-19 and a minute chance of death, whereas someone below these limits will have about a 90% chance of critical or fatal illness. A compilation of studies has shown  how critical is this level of 30ng/ml (75nmol/L). We can see this in the figure below, that when blood vitamin D level id below 30ng/ml the death rate is high, but it drops suddenly when the blood level is above this. I will explain the mechanism of this in a future Blog post.

The medico-political establishment in the UK has taken no notice of these studies. They have been critical of them for not being "peer reviewed", or "not randomised controlled trials", or "only observational", or "there is no proof". I will go into these absurdities in a future post, but for now it is as well to remember that the evidence that cigarette smoking causes lung cancer was also "observational". The attitude of the medico-political establishment brings to mind once again the response to the news of an approaching tsunami with an expected 40,000 casualties.

There has been another result from the Far East, this time from Singapore. In this study patients on admission to hospital with Covid-19 were randomly allocated to standard treatment or standard treatment plus treatment with a combination of Vitamin D, Magnesium, and Vitamin B12. Those on just the standard treatment had a significant disadvantage as judged by deterioration and need for oxygen therapy.

Although there was official silence about Vitamin D, word began to spread about its protective potential. The important step was paying attention to the deaths of the 24 BAME doctors, that the startling number of their excess deaths could only only be explained by inherited skin pigmentation and consequent vitamin D deficiency. The message seem to have spread very rapidly among BAME doctors,  and they were of course a group of people who were at high risk of death during the epidemic. Self-preservation is more important than "peer review" if you are on a beach when there is a warning of a tsunami (sorry to repeat the analogy for the second time).

A strange thing happened to me in early May. I needed petrol for my chain-saw (not for my car as I was "locked down" in the house). I went to the local petrol station and when I was paying, I asked the ethnic Asian manager Sajid, who I know well, if he takes vitamin D. He had never heard of it and so I gave him advice concerning his ethnicity and the imperative to avoid vitamin D deficiency during this pandemic. His colleague arrived and so he asked his colleague to make a FaceBook movie of me repeating what I had told him. This I did, unfortunately in my gardening clothes and without any forethought. However he sent it to his friends and it was then cascaded with perhaps viral spread. I received notice from ethnic Asian friends in London, the South East and South West of England and also from Dubai, that they had seen the movie. I was also told by friends in my locality that they had seen the movie, and they had also seen my comments reported in the local daily newspaper the Lancashire Telegraph.  

Sorry – the movie does not seem to work on the Blog

I was also told that "all" the local doctors in Blackburn are now taking vitamin D and recommending it to their patients. It is noticeable that the death rate from Covid-19 is lower in Blackburn than in neighbouring industrial towns with a large ethnic Asian population. 

It is also notable that deaths of BAME doctors has come to an end, the last death being on May 2nd in Ramsbottom, quite close to where I live. It appears that  that official ignorance and silence can be bypassed by a grassroots movement aided by traditional local newspapers and especially by social media. This appears to have happened within the BAME medical community in the UK: it is likely that the end of their deaths is because the great majority are now taking a vitamin D supplement.

Had this been "official" it could have been within a research programme, but it is just silent and although effective we are not really learning from it. However a retrospective survey could be undertaken to determine how many of the BAME doctors had started to take a vitamin D supplement during the pandemic, and especially during April 2020.

Although our Prime Minister tells us that we have "world-beating" something or other and that we are "beating" Covid-19, although observation leads to a different conclusion. Covid-19 is beating us. However the epidemic will subside as the population develops immunity. The UK is now fourth in the league of the most deaths per million population. Tiny and unfortunate San Marino heads the list. It is a tragedy for a nation (on the Adriatic coast of Italy) that has a population of only 33,400 and 42 Covid-19 deaths, 1257 per million. Also Andorra in the Pyrenees, with a population of 77,000 has had 51 deaths, 660 per million. The nations with deaths rates greater than 200 per million are shown in the figure below.

Of larger countries, Belgium has recorded 826 deaths per million and the UK 588 per million, just ahead of Spain and Italy. With 50,000 deaths the UK cannot really be considered to be "winning". Of course the mathematical model predicted a worst scenario 500,000 deaths. This was hardly sophisticated maths but primary school sums: 

If three quarters of the population of 65 million develop the illness, how many approximately will this be? Answer 50 million. If 1% of them die, how many will die? Answer 500,000. Thank you Neil Ferguson, professor mathematical biology and government advisor (now resigned).

What this means is that we can now regard 50,000 deaths as "winning", as it only one tenth of the absurd prediction. Remember that 200,000 died in the UK as the result of the terrible Spanish flu of 1918-19. About 30,000 in the UK died from the Asian Flu pandemic in 1957-58, and a maximum estimation of 80,000 from the Hong Kong Flu in 1968-69. 

We should have expected that during the 50 years since the last major pandemic, medical science would have thought of ways of protecting the population from serious and fatal death from what turned out to be Covid-19. Medical science has achieved that, but it appears to be too difficult for the medical scientists to understand or explain it to their political masters. Is it ignorance or is it ignoring that has kept the vital secret of the power of vitamin D to be withheld from the public?

What about the next inevitable pandemic of a virus that remains at present in its non-human animal host? How are we going to prepare for that?

During the past two weeks I have been working very hard with Professor David Anderson. We have written a book, which is now being prepared for release as an eBook, and later as a printed version.