Vitamin D Seems to Play a Role in Preventing Severe Illness and Death From #COVID19 #Coronavirus

intubation, mechanical ventilation, ventilator
If you have to be on a life-support breathing machine (ventilator), this qualifies as severe COVID-19 disease. Ventilator is at the bedside out of the picture. To tolerate the tube in your throat, you’ll be in the “medically-induced coma” you read about in the news.

From Northwestern Now:

After studying global data from the novel coronavirus (COVID-19) pandemic, researchers have discovered a strong correlation between severe vitamin D deficiency [based on blood levels] and mortality rates.

Led by Northwestern University, the research team conducted a statistical analysis of data from hospitals and clinics across China, France, Germany, Italy, Iran, South Korea, Spain, Switzerland, the United Kingdom (UK) and the United States.

The researchers noted that patients from countries with high COVID-19 mortality rates, such as Italy, Spain and the UK, had lower levels of vitamin D compared to patients in countries that were not as severely affected.

Our bodies have two source of vitamin D. Our skin can make it if given sufficient exposure to sunlight, or we can ingest it. Many folks don’t swallow and/or absorb enough of it, or don’t get enough sun exposure.

I’ve never been to Europe and readily confess I don’t know much about it. I figured the UK doesn’t get much sunlight, but Spain and Italy do (at least southern Italy). Maybe the heavy air pollution in northern Italy—e.g., Lombardi—blocks out the sun.

trees, forest, sunlight
Not a lot of sunlight penetrating through this forest

The researchers say that vitamin D keeps the immune system from over-reacting to the virus infection. A hyperactive immune system response causes widespread inflammation, which in turn damages various body tissues, leading to severe illness and sometimes death. This is the “cytokine storm” you may have heard about. That’s the theory anyway.

I never knew vitamin D was involved in the immune system, or if I did, I forgot. Like most physicians, my interest in vitamin D relates to calcium metabolism and bone health/fracture prevention.

Professor Backman is quoted in the article:

It is hard to say which dose [of vitamin D supplement] is most beneficial for COVID-19,” Backman said. “However, it is clear that vitamin D deficiency is harmful, and it can be easily addressed with appropriate supplementation. This might be another key to helping protect vulnerable populations, such as African-American and elderly patients, who have a prevalence of vitamin D deficiency.

Clicking this link may take you to the prepublication original research report.

A few days ago, CNN reported that black people are four times more likely to die from COVID-19 than are whites. Here in the U.S., we’ve seen disproportionately high fatalities among blacks living in Chicago, New Orleans, and Milwaukee County, Milwaukee. I’m not the first to wonder if vitamin D deficiency is a contributing factor. I mentioned earlier that our skin makes vitamin D when exposed to sufficient sunlight. But that process is less efficient in darker skin. And folks at more northern latitudes tend to get less sun exposure, particularly in winter. (Lack of sunlight shouldn’t be a problem in New Orleans). We’ve know for years that U.S. blacks have “sub-optimal” vitamin D blood levels. Click for even more reading on this issue if you’re crazy; it’s complicated. Despite low blood levels of 25-hydroxyvitamin D, blacks are not prone to thin-bone osteoporotic fractures like whites and east asians. Some experts suggest that higher rates of diabetes and hypertension in U.S. blacks is related to low vitamin D levels.

What we don’t know is:

  • If you have COVID-19 and try to augment your vitamin D level with a supplement, will you have a better outcome?
  • If you are deficient in vitamin D now but take measures to raise your blood level (via food or supplementation), will you be less likely to contract COVID-19 and able to avoid serious illness if you do get sick?
  • Would the answers to the first two questions depend on whether you have black, brown, white, pink, or polka-dotted skin?

Hey, doc. Tell me something concrete I can do now to improve my odds of surviving this pandemic!

If you’re black of otherwise dark-skinned, I don’t know what to tell you.

If you qualify as a vulnerable person, why not ask your doctor to order a vitamin D blood level (called 25-OH-vitamin D)? If that’s not possible, ask your doc if 1,000 units of vitamin D3/day (cholecalciferol) by mouth is a good idea.

     Steve Parker, M.D.

PS: About a week ago I ran across a study finding that pre-sickness use of vitamin D supplements was linked to worse outcomes in COVID-19. I tried to find it a few days later but couldn’t. I’m sorry if this perplexes you. Welcome to the scientific literature and nature of medical practice.

Face masks: Panacea or Poppycock? #COVID19

face mask, young woman
If she got the ‘rona, her mask my protect YOU, whether or not you wear a mask

Here’s an excerpt from the recent Danish study that questions the efficacy of facemarks in preventing transmission of SARS-CoV-2 virus. Note that there were ~3,000 folks in both the experimental and control groups. The experimental group wore surgical masks, so this study says nothing about cloth masks, N95s, or bandanas. Also note this study was done at at time early in the pandemic when mask-wearing by the public was not at all common, quite a bit different from today’s world in many places. The investigators suggest that for face masks to prevent transmission of the virus, the masks need to be worn by already-infected, viral-shedding people.

In this community-based, randomized controlled trial conducted in a setting where mask wearing was uncommon and was not among other recommended public health measures related to COVID-19, a recommendation to wear a surgical mask when outside the home among others did not reduce, at conventional levels of statistical significance, incident SARS-CoV-2 infection compared with no mask recommendation. We designed the study to detect a reduction in infection rate from 2% to 1%. Although no statistically significant difference in SARS-CoV-2 incidence was observed, the 95% CIs are compatible with a possible 46% reduction to 23% increase in infection among mask wearers. These findings do offer evidence about the degree of protection mask wearers can anticipate in a setting where others are not wearing masks and where other public health measures, including social distancing, are in effect. The findings, however, should not be used to conclude that a recommendation for everyone to wear masks in the community would not be effective in reducing SARS-CoV-2 infections, because the trial did not test the role of masks in source control of SARS-CoV-2 infection. During the study period, authorities did not recommend face mask use outside hospital settings and mask use was rare in community settings. This means that study participants’ exposure was overwhelmingly to persons not wearing masks.

Source: Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 0, No 0

Steve Parker, M.D.

Is a Patient With #COVID19 Infectious as Long as Their PCR Test Is Positive? #Coronavirus

artist's rendition of coronavirus
Artist’s rendition of Coronavirus

Investigators in the UK reviewed the literature of evidence on how long someone with COVID-19 remains infectious. Their answer: No longer than eight days after symptom onset. Source:

Viral cultures for COVID-19 infectivity assessment – a systematic review (Update 4) 

This is important to know because the PCR test for diagnosis of cases can remain positive for up to 83 days. Transmission of infection requires whole live virus – the more the better – not just the fragments of RNA that the PCR tests detect.

The best evidence for ongoing infectiousness is when virus from body fluids can be seen to grow in tissue cultures. Perhaps second best is when tissues or cell cultures are exposed to virus, and microscopic examination shows cell damage.

The commonly used clinical test of COVID-19 infection is called PCR (more accurately, reverse transcriptase polymerase chain reaction to RT-PCR). This test detects fragments of viral RNA, and amplifies them to make them easier to detect. The amount of amplification required for detection is called “cycle threshold” or Ct. If a lot of viral RNA is present, it doesn’t require much amplification. There are many different coronavirus tests on the market. If a test requires too much amplification (i.e., Ct is over 25-35), then it’s probably not a true positive test for SARS-CoV-2; it may be detecting RNA from some other coronavirus, or contamination. Interestingly, my patients have probably been tested with at least three or four different PCR tests over the last six months: the test reports I see never report their cycle threshold.

A false positive PCR test is one where the test is positive but the patient isn’t really infected. If you’re a government who wants a high “case” number, choose a test with a high Ct, over 30-35. (Again, it depends on the particular fragment of RNA being looked for, and other esoteric factors.)

The authors cited a couple cases of COVID-19 in which viral RNA was found in secretions at 78 and 83 days after initial diagnosis. They fully expect, however, that the RNA detected was viral debris, not whole infectious virus.

Remember, this is just one study. It hasn’t been peer-reviewed yet. We’re learning more as each month passes. Stay tuned.

Steve Parker, M.D.

British Medical Journal Editor Is Skeptical About #COVID19 Vaccines #Coronavirus

professor, equations
The governments “top men” are working on it

Peter Doshi, an associate editor at British Medical Journal, is not favorably impressed with the recent vaccine trial announcements. “90% effective.” “95% effective!”

Coronavirus guru Anthony Fauci assures us that a coronavirus vaccine will only be FDA-approved if it’s “safe and effective.”

From Doshi:

But what will it mean exactly when a vaccine is declared “effective”? To the public this seems fairly obvious. “The primary goal of a covid-19 vaccine is to keep people from getting very sick and dying,” a National Public Radio broadcast said bluntly.

Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, said, “Ideally, you want an antiviral vaccine to do two things . . . first, reduce the likelihood you will get severely ill and go to the hospital, and two, prevent infection and therefore interrupt disease transmission.”

Yet the current phase III trials are not actually set up to prove either. None of the trials currently under way are designed to detect a reduction in any serious outcome such as hospital admissions, use of intensive care, or deaths. Nor are the vaccines being studied to determine whether they can interrupt transmission of the virus.

Will COVID-19 vaccines save lives? Current trials aren’t designed to tell us.
elderly man, face mask
Do you ever wonder why we didn’t see widespread use face masks during a typical flu season in the past?

Switching gears to the flu vaccine for a minute. The flu vaccine’s been a godsend in preventing influenza death among the frail elderly, right? Not so fast there, pardner. Doshi again:

But the truth is that the science remains far from clear cut, even for influenza vaccines that have been used for decades. Although randomised trials have shown an effect in reducing the risk of symptomatic influenza, such trials have never been conducted in elderly people living in the community to see whether they save lives.

Only two placebo controlled trials in this population have ever been conducted, and neither was designed to detect any difference in hospital admissions or deaths.

Moreover, dramatic increases in use of influenza vaccines has not been associated with a decline in mortality.

The Moderna and Pfizer trials enrolled 30,000 and 44,000 participants, respectively. That sounds like a lot of people to be vaccinated. But they only vaccinate half the folks. The other have serve as a control group. Next, the investigators track the occurrence of coronavirus events over time, then compare the two groups. An “event” may be anything from a cough plus positive COVID-19 PCR test, to hospitalization or death. Of course, they also look at potential adverse effect of vaccination, comparing the two groups.

The trials aren’t going to give us good information on COVID-19 hospitalizations and death rates because those outcomes are so infrequent. Most people with symptomatic COVID-19 experience only mild symptoms; there are relatively few cases of serious disease in a general population of 30,000.

Who needs a safe and effective vaccine the most?

  • Those over 60-65
  • Anybody seriously immunocompromised (i.e., a poor immune system too weak to fight infection).

Immunocompromised people are excluded from the seven ongoing trials. So these trials focus on those over 60, right? Wrong. The Moderna trial eligibility started at age 18. Pfizer’s accepted 12-year-olds.

Surely the vaccine trials will have some participants over 60-years-old. There just may not be enough to generate clinically meaningful data on serious disease outcomes and adverse effects in the elderly.

Who’s paying the millions of dollars for these studies?

Steve Parker, M.D.

PS: I am not generally anti-vaccination.

Update on Nov 18, 2020:

Steven Novella says Moderna developed their vaccine with a grant from the U.S. government. Pfizer funded themselves. Each vaccine has cost over two billion dollars to develop. They will be the first ever mRNA vaccines approved by the FDA. Our other vaccines are based on different technology. Both vaccines require two shots, 28 days apart.

Virus Lockdowns Do More Harm Than Good #COVID19 #Coronavirus

face mask, elderly, worried
They survived the 1957-1958 Asian flu pandemic

New York Post has an article written by Dr. Martin Kulldorff, professor of medicine at Harvard University; Dr. Sunetra Gupta, an epidemiologist at Oxford University; and Dr. Jay Bhattacharya, a physician and epidemiologist at Stanford University calling for a different approach to dealing with the novel coronavirus than the lockdown model:

As infectious-disease epidemiologists and public-health scientists, we have grave concerns about the damaging physical and mental-health impacts of the prevailing COVID-19 policies and recommend an approach we call Focused Protection.

Coming from both the left and right, and around the world, we have devoted our careers to protecting people. Current lockdown policies are producing devastating effects on short- and long-term public health.The results (to name a few) include lower childhood-vaccination rates, worsening cardiovascular-disease outcomes, fewer cancer screenings and deteriorating mental health — leading to greater excess mortality in years to come, with the working class and younger members of society carrying the heaviest burden. Keeping students out of school is a grave injustice.Keeping these measures in place until a vaccine is available will cause irreparable damage, with the underprivileged disproportionately harmed.

Source: Medical experts: Lockdowns do more harm than good

The article ultimately links to the Great Barrington Declaration. The current number of medical practitioner signatories is 34,663. I signed on a couple weeks ago. It’s very similar to my proposal of early April 2020.

n95 mask, goggles
I’m ready for the 3nd wave in AZ
<p value="<amp-fit-text layout="fixed-height" min-font-size="6" max-font-size="72" height="80">Few of you will remember the <a href="https://www.cdc.gov/flu/pandemic-resources/1957-1958-pandemic.html">1957-1958 Asian flu (H2N2) pandemi</a>c. The estimated number of deaths was 1.1 million worldwide and <strong>116,000 in the United States</strong>. (U.S. population in 1957 was 172 million, half what it is now.) We didn't lockdown the population then. And we shouldn't now.Few of you will remember the 1957-1958 Asian flu (H2N2) pandemic. The estimated number of deaths was 1.1 million worldwide and 116,000 in the United States. (U.S. population in 1957 was 172 million, half what it is now.) We didn’t lockdown the population then. And we shouldn’t now.

Steve Parker, M.D.

#COVID19 Vaccine Manufacturers Won’t Take Responsibility for Adverse Effects

artist rendition of coronavirus
Artist’s rendition of coronavirus

Developing safe and effective vaccines is a costly and expensive endeavor. One way to motivate vaccine manufacturers is to guarantee up front that governments will purchase large quantities of vaccine. From NEJM:

Equally important is offering companies protection against potentially substantial liability should Covid-19 vaccines cause real or perceived injuries to recipients. Manufacturers won’t agree to procurement contracts or ship vaccine without liability protection. According to an AstraZeneca executive, for example, in the company’s bilateral contracts, it has been granted protection against legal claims arising from the use of its vaccine products, since it “cannot take the risk” of liability. As early as 2006, the International Federation of Pharmaceutical Manufacturers and Associations, the global pharmaceutical-industry lobbying group, publicly demanded that manufacturers be granted protection from lawsuits associated with vaccine-related adverse events if they were going to participate in pandemic responses. In the United States, the Public Readiness and Emergency Preparedness Act provides manufacturers immunity from lawsuits related to injuries caused by vaccines, with narrow exceptions. People injured by Covid-19 vaccines must file claims with a fund administered by the Department of Health and Human Services.

For a vaccine that will most likely be distributed worldwide, there is an inevitable risk of serious adverse events, such as seizures and allergic reactions, even with a very safe product. Such events might not begin surfacing until a substantial number of people have been vaccinated. During the 2009 H1N1 influenza pandemic, the incidence of serious adverse events after immunization varied by country. In the United States, the Vaccine Adverse Event Reporting System received reports of such events at a rate of 2.45 per 100,000 doses. China’s equivalent surveillance system found that 1083 of the 8067 adverse events recorded (1.21 per 100,000 doses) were serious. Compensation costs also varied. One H1N1 vaccine that contained an adjuvant was associated with an increased risk of narcolepsy, which resulted in substantial compensation claims in Northern European countries.

Source: No-Fault Compensation for Vaccine Injury — The Other Side of Equitable Access to Covid-19 Vaccines | NEJM

So the vaccine manufacturers smartly offload the liability risk onto governments. The manufacturers don’t mind at all if fears of COVID-19 are overblown: they sell more vaccine in that environment. Looking at all comers, the risk of death or serious adverse effects from COVID-19 are under 0.5% for an individual. The full risks of an adverse effect from a vaccine may not be known for several years after release. This is why so many folks will be reluctant to take the vaccine. The risk:benefit ratio will vary with your age and co-morbidities. For instance, an obese 70-year-old with diabetes, heart failure, and emphysema may benefit from the vaccine very much more than a healthy 25-year-old.

Steve Parker, M.D.

PS: Reduce your risk of death by getting and staying as healthy as possible. Let me help:

How to Have a Virus-Free Thanksgiving #COVID19 #Coronavirus

thanksgiving, turkey, family
No masks and no social distancing

Click for the Centers for Disease Control’s advice. Like don’t travel. Six-foot social distancing. Have guests (risky!) bring their own food, beverages, and utinsils. Eat outdoors.

My family will be ignoring many of many of the CDCs tips. We’ve invited an elderly couple over to the house, and they’re not very healthy. My son and stepson are coming in from out of town. We’re eating indoors.

But we’ll wash our hands more than usual.

I’m wishing you an happy and healthy Thanksgiving with people you love. You can’t be sure when or if you’ll see them again.

Steve Parker, M.D.

Ketogenic Diet Dramatically Reduces Liver Fat in Non-Alcoholic Fatty Liver Disease #NAFLD

stages of liver damage
<p class="has-drop-cap" value="<amp-fit-text layout="fixed-height" min-font-size="6" max-font-size="72" height="80">Excessive fat accumulation in the liver is also referred to as fatty liver or hepatic steatosis. When enough fat accumulates, it starts hurting the liver, then we call it non-alcoholic fatty liver disease (NAFLD). This can lead to cirrhosis in which scar tissue replaces healthy liver cells, and is one of the leading reasons for liver transplantation. Experts debate which is the best diet for reducing liver fat, but nearly all agree that losing overall excess body weight is helpful, assuming a well-designed diet that avoids nutritional deficiencies. Excessive fat accumulation in the liver is also referred to as fatty liver or hepatic steatosis. When enough fat accumulates, it starts hurting the liver, then we call it non-alcoholic fatty liver disease (NAFLD). This can lead to cirrhosis in which scar tissue replaces healthy liver cells, and is one of the leading reasons for liver transplantation. Experts debate which is the best diet for reducing liver fat, but nearly all agree that losing overall excess body weight is helpful, assuming a well-designed diet that avoids nutritional deficiencies.

Fat in the liver and elsewhere in the body is composed almost entirely of molecules called triglycerides. When you lose fat weight, you’re converting the triglycerides into energy your body can use.

<p value="<amp-fit-text layout="fixed-height" min-font-size="6" max-font-size="72" height="80">Here's a study that found dramatic results in just six days:Here’s a study that found dramatic results in just six days:

Ketogenic diet is an effective treatment for nonalcoholic fatty liver disease (NAFLD). Here, we present evidence that hepatic mitochondrial fluxes and redox state are markedly altered during ketogenic diet-induced reversal of NAFLD in humans. Ketogenic diet for 6 d markedly decreased liver fat content and hepatic insulin resistance. These changes were associated with increased net hydrolysis of liver triglycerides and decreased endogenous glucose production and serum insulin concentrations.

Source: Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease

Steve Parker, M.D.

The Ketogenic Mediterranean Diet is incorporated into the Advanced Mediterranean Diet, 2nd edition.

Image

Seen at my Local AnyTime Fitness #Humor

The Electoral College Declares the President-Elect, Not the Mainstream Media

I’m neither a Republican nor Democrat and this is not a political blog. However I do have at least a little concern that the recent U.S. presidential election was influenced by fraudulent “voting.” Investigations are underway and maybe we’ll have an answer by Dec 14, 2020, the deadline for the electoral college to declare a clear and legal winner. I’m reproducing these tweets here, hoping that they’ll be preserved even if Twitter decides to censor and delete them. Twitter would not allow me to copy one of President Trump’s tweets of Nov 7.

On a lighter note, here’s a pic of a jade plant started from a clipping from an outdoors jade plant from Oceanside, CA, from summer of 2019. It has tripled size since then, but does not do well in 100+ degree heat.