Covid-19 & Vitamin D : do not sit on the fence when there is blood on the floor

Covid-19 & Vitamin D

No sitting on the fence: there is blood on the floor!

2008. I just managed to get out of the way !

When the pandemic of Covid-19 appeared a year ago there was a great deal of evidence predicting that our known widespread deficiency of vitamin D would cause a serious problem. It would produce a problem of sub-optimal immunity, and thus a high risk of death from critical or fatal infection. And this is what happened. As expected the deaths occurred in excess in communities known to have a high prevalence of vitamin D deficiency: the ethnic Black African and Asian (BAME), the obese, and the elderly in particular. 

The early missed opportunity

There could have been community-based blood testing to detect individuals with vitamin D deficiency, but it did not happen and vitamin D testing was discouraged by public health bodies. Vitamin D could have been given to all, on the basis that in a single dose of 100,000 units it would have corrected deficiency of those deficient and would have done no harm to those not deficient. Blood testing within the following three months would identify the need to continue with a supplement. Alternatively a vitamin D supplement dose of 20,000 units each week or 3,000 units each day would have been appropriate and perfectly safe.

But official correction of vitamin D deficiency did not happen. We had to wait for more than 100,000 deaths before vaccines became available. 

We have had a large number of "scientists" who have dominated the political agenda. There have been mathematicians, statisticians, epidemiologists, virologists, nutritionalists, sociologists, the chief medical officer and the chief scientists, both of who have enjoyed an academic career. Some of them have mentioned vitamin D with a remarkable lack of enthusiasm, in complete contrast to their embrace of vaccines.

The dead hand of NICE

The reason for the denial of use of vitamin D has never been clear. The large amount of evidence from the forty years preceding the pandemic made little difference to official advice. Reference was always made to the reports by NICE, the National Institute for Health and Care Excellence. 

The reason why the correction of a vitamin deficiency had to be referred to NICE is difficult to understand, as it would be an automatic clinical duty to correct a vitamin or hormone deficiency, be it vitamin D, vitamin C, vitamin B12, the prescription of insulin or thyroxine and so on. But NICE has somehow been given the responsibility for the correction of vitamin D deficiency, and a series of its reports failed to approve the use of vitamin D, but always failing to acknowledge deficiency. 

NICE informed the nation of a lack of evidence and demanded randomised controlled clinical trials (RCTs). 

A report from NICE on June 29th told us that:

"There is no evidence to support taking vitamin D supplements to specifically prevent or treat Covid-19" 

This avoided any mention of the fact that research points to the majority of the population being deficient of vitamin D. If NICE is supposed to help doctors in their treatment of ill patients, it failed miserably to do so. The response has been very far from Excellent.

Once again more evidence, randomised controls were demanded. The result of the first RCT, from Córdoba, Spain, appeared on September 3rd. The response of NICE was that the (very positive) result should have no influence on the way in which doctors treat patients (with Covid-19 pneumonia). 

"The clinical management of patients with COVID-19 should not be changed based on the results of this study."

On December 18th NICE published a joint report with SACN (Scientific Advisory Group on Nutrition) and PHE (Public Health England) in which Sir Paul Chrisp (director of the centre for guidelines at NICE) stated:

"While there is insufficient evidence to recommend vitamin D for the prevention or treatment of Covid-19 at this time, we encourage people to follow government advice on taking the supplement thought the autumn and winter period."

The reason for this change of direction is that the Health Secretary Matt Hancock had stepped outside NICE advice. He had become aware of the importance of vitamin D in the prevention of Covid-19 and he issued a directive that all elderly people should be issued with a vitamin D supplement. NICE could not disagree with a minister and so it had to use double-speak, taking advantage of the many synonyms in the English language. To "recommend" and to "encourage" are verbs without an obvious difference in meaning.

NICE cannot be regarded as having the best interests of the sick and dying at heart.

NICE denies responsibility

The full NICE report that included the first RCT of vitamin D as 25(OH)D or calcifediol, its natural rapidly-acting form, appeared in December 2020. Although the earlier report carried its "recommendation" that doctors should not have their treatment of patients be influenced by this first RCT, the full report carried an interesting disclaimer:

"The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian."

NICE and other documents carried generally very negative reviews of vitamin D, and denied the role of vitamin D in defensive immunity, ignoring the accumulated evidence. It has been the same in other commentaries, at best balanced, always stating a need for more research, but when is there not a need for more research? Does science ever stand still? Is a balanced view of help to a doctor caring for the sick and dying?

There was undue publicity given to two barely comprehensible papers that were pre-published in January 2021. 

One was from Canada, the other was from Greece.They stated that there was no evidence of benefit from vitamin D. They were of very poor quality and added nothing, but headlines were dramatic.

The very positive result of the second controlled trial, from Barcelona, has received no official comment. It was "rejected" by Professor Adrian Martineau, a member of NICE. Still a demand for more RCTs that would inevitably necessitate more human sacrifice.

No evidence?

The common suggestion of "no evidence" is absurd. Let us assume that there had been a murder and that ten detectives were sent out to investigate. On the following day eight detective returned to HQ and reported that they had all found incriminating evidence that pointed to one man who appeared to be guilty of the crime. On the following day the other two detectives returned and stated that there was no evidence of the accused man being responsible for the crime. Would their finding of "no evidence", or rather their failure to find evidence, invalidate the evidence found by the others? 

Of course there is ample evidence to suggest that vitamin D would be of benefit in Covid-19, but most people seem to be unaware of it.

A view from an ivory tower

A recent editorial in the British Medical Journal on the subject of Covid-19 and vitamin D was written by two nutritionalists and a professor of primary care diabetes, the latter having previously written what I can only describe as a non-medical appraisal of the high Covid-19 death rate of BAME people without once mentioning vitamin D! Even though it was in the British Medical Journal, the editorial was of no practical value to practising doctors. There was no practical advice as to how to reduce the deaths from Covid-19 in any ethnic groups. 

"Existing evidence supports a compelling case for further research." Let's just kick the can down the road while more people die. 

The authors of this editorial, like perhaps all commentators on the subject of Covid-19 and vitamin D, did not have responsibility for patients admitted to hospital with Covid-19 pneumonia. Whether or not they themselves took vitamin D was not declared. They gave no advice as to whether such patients should be treated with calcifediol as in the Córdoba protocol, but they gave ample discouragement. 

Advisors to government but not to doctors

Government advisors on the Covid-19 pandemic live in offices, ivory towers. They do not live in the emergency areas of hospitals. They never see blood on the floor. They do not know what it is like to make life or death decisions. They do not understand the pressure to do the very best to help an individual patient. But they inhibit rather than help those front-line doctors who need support.

A report in December 2020 from an all-party committee of parliament also managed to find no place for vitamin D. The ignorance is wide-spread.

MD in Private Eye is not one to follow central directives, but his first and very brief mention of vitamin D during the pandemic informed us that "The jury is still out". He followed this by a plea to be given vitamin D should he develop Covid-19 (Eye 1452). If the jury is still out it indicates that evidence has been withheld or that the judge has failed to give direction. However MD showed some of the pragmatism that doctors require, but in advice to others he followed the official line: he clearly sat on the fence of indecision.

Clinical decisions

For a clinical doctor to make a decision to prescribe vitamin D / calcifediol for a patient with Covid-19 pneumonia is actually very straightforward and I am sure that non-one would argue with it. Surely a doctor would not regard herself or himself of being at risk of charges of negligence or other disciplinary charge should vitamin D be prescribed. But doctors are frightened of giving vitamin D. 

Decision-making is encapsulated in Pascal's Wager, that I have described previously.

To give vitamin D as calcifediol to a patient admitted to hospital with Covid-19 pneumonia would have a high probability (about 70%, but not certainty) of reducing the need for ICU transfer and death, and it would have a cost of about £10, with no side-effects. 

To deny the patient calcifediol would correspondingly fail to reduce the need for ICU transfer and failed to reduce the number of deaths.

What could be a more simple decision than this? Obviously vitamin D / calcifediol must be given, that is if the objective of the doctor is to minimise illness and reduce the chance of the death of a patient. Can anyone provide a reason why a patient critically ill with Covid-19 pneumonia should not be treated with calcifediol, or why anyone deficient in vitamin D not have the deficiency corrected?

Why is calcifediol not being given to patients with Covid-19 pneumonia in the UK? Because NICE says that it should not be given. Doctors and their managers are frightened of not obeying NICE. Can NICE justify it actions in denying vitamin D to those are dying?

Legal claims

It has just emerged that there is a now a group legal claim against the UK government as to why not more was done to protect the population, so as to keep the number of deaths well below 125,000. 

The legal claim is bound to uncover the fact that vitamin D and its active metabolite calcifediol (25(OH)D) had been withheld, when all the evidence pointed to it being very helpful and life-saving. 83,000 people have died since the result of the Córdoba study became available on September 3rd, and a significant number of these deaths were therefore avoidable. The question in a court of law would be, "Why was vitamin D not given?" The government will point out that it was only following the advice given by NICE. NICE will defend itself by pointing out its disclaimer, which I will repeat as it is vitally important in its defence. The disclaimer must have been written by lawyers.

"The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian."

Who will be held guilty?

This declaration clearly shifts the blame for the deaths of patients to hospital doctors, for following its repeated advice!

This is a disgrace.

The responses of doctors and their professional organisations, and the General Medical Council will be interesting.