The importance of Vitamin D in the Covid-19 pandemic: reports from Israel
It has been known for more than 40 years that vitamin D is of vital importance in the escalation of defensive immunity at the time of infection. It is also well-established that people with defective immunity are very susceptible to infection, with a high risk of death, and this has been illustrated well by the experience of AIDS. It has also been established on numerous occasions in many countries that vitamin D deficiency is very common, leading to sub-optimal immunity in many people.
In life in general, people are not aware of their vitamin D deficiency and the problems that result from it. Health issues such as respiratory infections, post-operative infections and recovery from surgery, problems in pregnancy, the development of diabetes, certain cancers, and multiple sclerosis are accepted as bad luck, even though they are known to have an increased incidence in people with vitamin D deficiency.
But when faced with a pandemic of Covid-19, a virus against which we have no learned immunity, the rapid time-scale brought disadvantages of vitamin D deficiency and impaired immunity into sharp focus. It was soon after the onset of the pandemic that we learned of the high susceptibility of those with low blood levels of vitamin D to critical and fatal Covid-19. It was obvious that a public health imperative to minimise ICU admissions and deaths, would be to correct vitamin D deficiency as soon as possible. But it was not to be.
Susceptibility of particular population groups
It became clear that the great majority of Covid-19 deaths occurred in the elderly, but we were told that they were just old, the official and unquestioned narrative that had no scientific foundation. Vitamin D is produced by the action of UV from the sun on 7-dehydrocholesterol (7-DHC) that is synthesised in the skin. It has been known for forty years that the thin dry skin of the elderly does not synthesise adequate amounts of 7-DHC and so vitamin D deficiency is inevitable, no matter how much time is spent in the sun.
It was also clear that people of Black African and South Asian ethnicity were particularly susceptible to critical and fatal Covid-19. The official narrative is that this has been the result of socio-economic disadvantage and racism. My reporting of the fact that of 26 working doctors in the UK who died from Covid-19, 25 (96%) were of Black African and South Asian ethnicity went officially unacknowledged even though it was the paradox that invalidated the socio-economic proposal. Well-known vitamin D deficiency in these ethnic groups was the obvious and scientifically established explanation, not officialy acknowledged.
In a previous Blog post I reported that the group of people in the UK hit hardest of all by the pandemic of Covid-19 have been Haredi Jews, those who are most orthodox. I pointed out that they have sun-avoiding behaviour, not by intent but as a result of clothing and other traditions that result in virtually no exposure of the skin to the sun.
VItamin D in Israel in 2001
Research in Israel 20 years ago investigated vitamin D status in Jewish new mothers in Israel, identifying as to whether they were orthodox (Haredi) or non-orthodox. Blood testing for vitamin D was undertaken after delivery. It was found that in the orthodox mothers the average mean blood level of vitamin D was 13.5ng/ml (34nmol/L) compared to 18.6ng/ml (46.5nmol/L) in non-orthodox mothers.
We can see in Figure 1 that extremely low blood levels of less than 5ng/ml, 12.5nmol/L, were found in 5.7% of orthodox mothers and in 2.7% of non-orthodox. Less than 10ng/ml (25nmol/L) was found in 32.7% of orthodox mothers and in 13% of non-orthodox. We will see from a later study how extremely low are these blood levels.
A very small vitamin D supplement of 400 units per day was given to some women during pregnancy and it had a small effect. As a result of this supplement, 2.2% of orthodox mothers had a blood level less than 5ng/ml, 12.5nmol/L, but none of the non-orthodox mothers. 13% of the orthodox mothers receiving the small vitamin D supplement had a blood level less than 10ng/ml, 25nmol/L, compared to 8% in non-orthodox.
|Figure 1. Jewish mothers in Israel – vitamin D status|
The messages from this study are that:
- vitamin D deficiency is very common in Israel, despite a sunny environment
- it is more common in orthodox mothers
- vitamin D supplement of 400 units per day is of little benefit
- blood levels of vitamin D are higher in the summer in non-orthodox mothers
- in orthodox mothers, blood levels of vitamin D do not increase in the summer.
Mukamel MN, Weisman Y, Somech R, et al. Vitamin D deficiency and insufficiency in orthodox and non-orthodox Jewish mothers in Israel. Isr Med Assoc 2001; 3: 419-421.
Vitamin D in Israel in 2021
We now have the results of a new study from Israel. It looks at the outcome of Covid-19 related to pre-infection Vitamin D status, and "Guess What?" The outcome is far better in people with the highest (not toxic) blood levels of Vitamin D. Let us look at the details.
The study was of 1176 patients admitted to the Galilee Medical Centre on account of Covid-19. 253 of these had blood levels of Vitamin D measured prior to infection. For the purpose of analysis they were divided into four groups based on blood levels:
- less than 20ng/ml, 50nmol/L
- 20 to 29.9ng/ml, 50 to 75nmol/L
- 30 to 40ng/ml, 75 to 100nmol/L
- greater than 40ng/ml, 100nmol/L.
The analysis shows many interesting features, as displayed in the tables and figures.
|Figure 2. Blood levels of Vitamin D in advance of Covid-19|
Figure 2 shows the distribution of blood levels of Vitamin D. 52.5% of those admitted to hospital had a previous blood level less than 20ng/ml, 50nmol/L. This in itself identifies a serious public health problem that was identified in new mothers in 2001 and remains twenty years later. Only 15.8% had a level greater than 40ng/ml, 100nmol/L.
Table 1 shows the relationship between the blood levels of Vitamin D in advance of Covid-19 and the severity of illness when it happened. The Table shows the numbers in each group, and also the percentages of Vitamin D status in each illness category.
|Table 1. Relationship between severity of Covid-19 and pre-existing blood levels of Vitamin D|
Table 2 illustrates the dramatic effect of pre-existing blood levels of Vitamin D on death from Covid-19. A blood level of greater than 20ng/ml, 50nmol/L, makes death very unlikely. A blood level of less than this put an individual at considerable risk of death, an excess risk that can be eliminated by the public health action of correcting Vitamin D deficiency.
|Table 2. Deaths from Covid-19 and pre-existing blood levels of Vitamin D|
We can see in Figure 3 that most patients with mild illness have higher blood levels of Vitamin D, greater than 30ng/ml, 75nmol/L.
|Figure 3. Blood levels of Vitamin D in patients with mild Covid-19|
When we look at Figure 4 we find that in moderate illness the patients are predominantly those with low blood levels of Vitamin D
|Figure 4. Blood levels Vitamin D in patients with moderate Covid-19|
Figure 5, below, shows that severe Covid-19 occurs almost exclusively in those with low levels of Vitamin D, less than 20ng/ml, 50nmol/L.
|Figure 5. Blood levels Vitamin D in patients with severe Covid-19|
Figure 6 shows that critical Covid-19, patients, those who would have been admitted to intensive care, were almost exclusively those with the lowest blood levels of Vitamin D. On the other hand patients with blood levels greater than 30ng/ml, 75nmol/L, did not require intensive care unit support.
|Figure 6. Blood levels Vitamin D in patients with critical Covid-19|
We can look at this is another way. What is the pattern of illness that occurs with Covid-19 in people with the lowest blood levels of Vitamin D, less than 20ng/ml, 50nmol/L?
Figure 7 demonstrates that those with the lowest blood levels of Vitamin D are most likely to have severe or critical illness.
|Figure 7. Covid-19 in patients with the lowest blood levels of Vitamin D, <20ng/ml <50nmol/L|
When the blood level of Vitamin D is above the critical level of 20ng/ml, 50nmol/L, the threat of severe or critical illness is very much reduced, as shown in Figure 8.
|Figure 8. Covid-19 in patients with blood levels of Vitamin D|
When the blood level of Vitamin D is greater than 30ng/ml, 75nmol/L, Covid-19 is likely to be mild, shown in Figure 9.
|Figure 7. Covid-19 in patients with blood levels of Vitamin D|
Figure 10, below, shows that when the blood level of VItamin D is greater than 40ng/ml, 100nmol/L, severe and critical Covid-19 does not occur. 12 patients out of 13 had just mild illness, and one had just moderate illness.
|Figure 7. Covid-19 in patients with the highest blood levels of Vitamin D, >40ng/ml, >100nmol/L|
38 of the 253 patients died. Deaths, occurring in hospital, were almost entirely in patients with the lowest levels of Vitamin D, less than 20ng/ml, 50nmol/L. (Table 2, repeated)
|Table 2. Deaths from Covid-19 and pre-existing blood levels of Vitamin D|
It appears that the three patients who died with blood vitamin D levels of 30ng/ml, 75nmol/L, they did so without going to the Intensive Care units, for reasons not explained.
For the purpose of death analysis, there are just two groups, those with vitamin D less than 20ng/ml, 50nmol/L (34 patients), and those with higher levels (4 patients).
If you were to develop Covid-19, what blood level of Vitamin D would you choose?
|Figure 11. Deaths from Covid-19 and pre-existing blood levels of Vitamin|
The study did not distinguish between orthodox and non-orthodox Jews, but we have seen that in the UK orthodox Haredi Jews have had an exceptionally high mortality rate from Covid-19. The two main ethnic groups in Israel are Jews and Arabs, but there are several minority ethnic religious groups within Arab people. For the purpose of analysis, the study divided its sample into Arab and non-Arab.
The Vitamin D status of the two groups is shown in Figure 12.
|Figure 12. Blood levels of Vitamin D in Israel|
The frequency of very low blood levels of vitamin D less than 20ng/ml, 40nmol/L, is almost twice as high in the Arab group as in the non-Arab. The reason is not investigated directly, but is most likely to be the result of sun-avoiding behaviour, with very little exposure of the skin to the sun in Muslim people.
There is no mention of illness category or mortality related to ethnicity, but we can assume that the large proportion of Arab people with very low blood levels of Vitamin D would lead to a high incidence of serious and fatal disease. It is likely that, as in the UK, this will also be the case in the most orthodox Jews.
The age categories for analysis are:
- less than 50 years
- 50 to 65
- 65 and older
The relationship between age and vitamin D status is shown in Figure 13.
|Figure 13. Blood levels of Vitamin D related to age|
The result is not surprising. Older people have on average lower blood levels of vitamin D. In this study, of the patients with Covid-19 aged 65 or older (grey bars), 59.4% had blood vitamin D levels less than 20ng/ml, 50nmol/L, compared to just 13.5% of those aged less that 50 years.
We have seen above that older people progressively fail to synthesise adequate amounts of 7-dehydrocholesterol, and as a result UV from the sun is unable to produce sufficient vitamin D to enable optimal immunity.
Vitamin D levels in co-morbidities
The 2021 study from Israel provides additional data of considerable importance, an analysis of co-morbidities.
It has been recognised in the UK and other European countries that Black African and South Asian ethnicities, and increasing age were major factors in the risk of serious, critical, and fatal Covid-19. But certain pre-existing illnesses, co-morbidities, were also recognised as increasing such risk. These are not surprising to those who are aware of clinical practice. The co-morbidities recognised in the study from Israel are as follows:
- COPD, chronic obstructive pulmonary disease
- CHD, coronary heart disease
- CKD, chronic kidney disease
- Obesity, BMI >30
The relationship of these to blood levels of Vitamin D are shown in Table 3.
|Table 3. Covid-19, co-morbidities, and pre-existing blood levels of Vitamin D|
Absolute numbers in each group are shown in Table 3, and it is obvious that all these co-morbidities are strongly associated with the lowest blood levels of vitamin D, less than 20ng/ml, 50nmol/L.
A study performed in the UK in early 2021 demonstrated the same thing and I have reviewed it previously. It demonstrated very similar findings to this table, but the findings were interpreted in an absurd way. If there was a high Covid-19 death rate from CHD, age, or ethnicity, then these were the stated reasons and Vitamin D deficiency was regarded as incidental. In other words the interpretation was that there was no evidence that Vitamin D deficiency was of any importance. The vitamin D deficiency of ethnic minorities was left untreated, with countless deaths resulting. The paper completely failed to follow the scientific process of finding the common factor (in this case Vitamin D), a vital step in understanding as described by William of Ockham.
The conclusion of this well-publicised but extremely poor UK study was ultimately withdrawn, but this was not reported in the national press.
The Israel study accepts that the totality of the data indicate a pivotal role of pre-existing blood levels of Vitamin D in predicting the outcome of Covid-19.
The conclusions and implications of the two studies from Israel are perfectly clear and irrefutable. The blood level of Vitamin D is the major determinant of outcome from symptomatic Covid-19. The target blood level must be 40ng/ml, 100nmol/L, so as to optimise immunity against severe and critical Covid-19. Had this approach been instituted as a public health initiative at the onset of the Covid-19 pandemic, there would have been many fewer deaths and very much reduced pressure on hospitals and intensive care units.
Blood level of Vitamin D less than 20ng/ml, 40nmol/L, should be regarded as critically low and requiring immediate correction. Testing the population for blood level of Vitamin D must become a public health policy. This is easily affordable.
More work is required to establish the dose of Vitamin D that is required to correct inadequate blood levels. The 2001 study from Israel indicated clearly that 400units per day given during pregnancy was hopelessly inadequate and did not eliminate serious Vitamin D deficiency. This is the dose that UK heath agencies advise, but they state that the more realistic dose of 4,000 units per day is safe. This is the dose that is regarded as appropriate by most medical scientists who study Vitamin D.
I have indicated previously that by definition and before the days of physical measurement, one unit of Vitamin D was defined as the daily requirement of a 10 gram immature mouse. We can scale up from that so that the daily requirement of a 60kg human would be 6,000 units, and for a 120kg obese human 12,000 units each day. To be cautious, perhaps half of these doses would be a reasonable starting point for determining the dose that would be appropriate in achieving the blood levels of 40ng/ml, 100nmol/L. This must be the target level, as the study from Israel indicates.