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11 percent fewer COVID-19 deaths if lockdowns had allowed sunshine – Nov 2021

Comprehensive model covering 155 countries from Feb to early Oct 2020.
Approximately 100,000 deaths.   PDF

Association of lockdowns with the protective role of ultraviolet-B (UVB) radiation in reducing COVID-19 deaths

Sci Rep . 2021 Nov 24;11(1):22851. doi: 10.1038/s41598-021-01908-w.
Rahul Kalippurayil Moozhipurath 1, Lennart Kraft 2


Nations are imposing unprecedented measures at a large scale to contain the spread of the COVID-19 pandemic. While recent studies show that non-pharmaceutical intervention measures such as lockdowns may have mitigated the spread of COVID-19, those measures also lead to substantial economic and social costs, and might limit exposure to ultraviolet-B radiation (UVB). Emerging observational evidence indicates the protective role of UVB and vitamin D in reducing the severity and mortality of COVID-19 deaths. This observational study empirically outlines the protective roles of lockdown and UVB exposure as measured by the ultraviolet index (UVI). Specifically, we examine whether the severity of lockdown is associated with a reduction in the protective role of UVB exposure.

We use a log-linear fixed-effects model on a panel dataset of secondary data of 155 countries from 22 January 2020 until 7 October 2020 (n = 29,327). We use the cumulative number of COVID-19 deaths as the dependent variable and isolate the mitigating influence of lockdown severity on the association between UVI and growth rates of COVID-19 deaths from time-constant country-specific and time-varying country-specific potentially confounding factors. After controlling for time-constant and time-varying factors, we find that a unit increase in UVI and lockdown severity are independently associated with - 0.85 percentage points (p.p) and - 4.7 p.p decline in COVID-19 deaths growth rate, indicating their respective protective roles. The change of UVI over time is typically large (e.g., on average, UVI in New York City increases up to 6 units between January until June), indicating that the protective role of UVI might be substantial. However, the widely utilized and least severe lockdown (governmental recommendation to not leave the house) is associated with the mitigation of the protective role of UVI by 81% (0.76 p.p), which indicates a downside risk associated with its widespread use. We find that lockdown severity and UVI are independently associated with a slowdown in the daily growth rates of cumulative COVID-19 deaths. However, we find evidence that an increase in lockdown severity is associated with significant mitigation in the protective role of UVI in reducing COVID-19 deaths. Our results suggest that lockdowns in conjunction with adequate exposure to UVB radiation might have even reduced the number of COVID-19 deaths more strongly than lockdowns alone. For example, we estimate that there would be 11% fewer deaths on average with sufficient UVB exposure during the period people were recommended not to leave their house. Therefore, our study outlines the importance of considering UVB exposure, especially while implementing lockdowns, and could inspire further clinical studies that may support policy decision-making in countries imposing such measures.

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Discussion section

Our empirical results indicate that large-scale lockdowns are associated with a substantial slowdown in the daily growth rates of COVID-19 deaths consistent with prior studies1. However, such measures also significantly reduce the protective role of UVB in COVID-19 deaths.
Specifically, we find that unit increases in UVI and lockdown severity are independently associated with a decline in the growth rate of COVID-19 deaths, indicating their respective protective roles. However, the lowest lockdown severity (recommendation not to leave the house) is already associated with almost complete mitigation of the protective role of UVI in reducing the growth rate of COVID-19 deaths via a reduction of 0.76 percentage points or -81% (p < 0.001). Our results are consistent across different model specifications.
Our results suggest that lockdowns in conjunction with adequate exposure to UVB radiation might have provided even more substantial health benefits than lockdowns alone. For example, we estimate that there would be 11% fewer deaths on average with more UVB exposure while people were recommended not to leave their houses.
Our contributions are three-fold. First, to the best of our knowledge, this study is one of the first ones that outlines the association between the severity of lockdown, the subsequent reduction in UVB exposure, and COVID-19 deaths. Second, our study outlines the need for further large-scale clinical studies exploring the role of vitamin D in mitigating the pandemic. Third, even though emerging studies suggest the need for continued large-scale interventions1,2, in addition to substantial economic and social costs, the findings of our study indicate that an unintended consequence is the limited UVB exposure, which plausibly increases the risk of COVID-19 deaths. The results of our study can therefore inspire observational or experimental clinical studies that can further support COVID-19 related policy decision-making in countries that are currently implementing lockdowns or are considering them in the future to slow down COVID-19 growth. Specifically, such clinical studies may investigate if sensible sunlight exposure in conjunction with lockdown or with proper social distancing can mitigate COVID-19 deaths. Sensible UVB exposure is possible during lockdown by spending time outside in a garden, on balconies, or by exposing to sunlight through open windows. Further, the results of large scale clinical studies could help guide nations to create awareness regarding the importance of sensible sunlight exposure and also to assist vulnerable populations at a higher risk of vitamin D deficiency—e.g., darker-skinned people living in high latitudes, people with limited mobility or indoor lifestyle (nursing home residents), and vegetarians8.

Limitations section

We follow a macro-level statistical backward-looking approach that captures real-life behavior without making any specific assumptions regarding epidemiological parameters1. Although this macro-level approach is a crucial strength of the study, the results cannot be interpreted as health guidance, which often comes from clinical studies1. Therefore, further clinical studies are needed to establish a causal relationship between UVB-induced vitamin D and COVID-19 deaths.
We use a fixed-effects model that isolates the effect of relevant weather parameters from country-specific time-constant factors8. Such country-specific time-constant factors consist of various economic, social, and health factors that are likely to remain relatively stable over the period of our study8. The time constant factors include the location (e.g., latitude and longitude), demographics, age composition, gender, genetics, and culture at a country level8. More importantly, such time-constant factors include factors that are closely associated with the severity of COVID-19, such as age, gender, mobility, lifestyle of the population, the prevalence of co-morbidities (e.g., obesity, hypertension, etc.), and skin pigmentation8. Fixed-effects also may capture factors associated with regular habits such as regular dietary patterns, the proportion of vegetarians in the population, regular dietary supplement consumption, and food fortification that may affect COVID-19 severity8.
Our methodology also flexibly controls for various time-varying factors8. First, our methods control for relevant confounding time-varying weather factors, including air pollution. Second, we control for various remaining time-varying factors by incorporating linear, quadratic, and exponential time-trends at a country level8 in the robustness checks of the Supplementary Appendix. These flexible time-trends control for time-varying factors such as pressure on the health care system and exponential-shaped or s-shaped trends associated with the COVID-19 growth rate.
Although our methodology controls for all time-constant and various time-varying confounding factors, we acknowledge that our method has limitations. First, our method may be limited in capturing some of the time- varying confounding factors that may confound the results. For instance, our methodology may not capture behavioral changes of the people that are likely to be associated with seasonal changes (UVB variation), vitamin D levels, and COVID-19 deaths. For example, such time-varying behaviors include seasonal travel patterns, seasonal nutritional supplement intake, and seasonal dietary habits8. Second, although we use governmental measures, we do not have granular data on whether people comply with these measures. Therefore, we have limited information about whether people followed governmental instructions and stayed indoors during the lockdown. Third, we do not have data on the vitamin D level at a population level across these countries corresponding to the UVB radiation that prevents us from directly analyzing the association between COVID-19 deaths and vitamin D levels. Finally, our study is an ecological study based on country-level data and therefore has inherent limitations that are commonly associated with such ecological studies.
Even though we anticipate that reduced likelihood of skin synthesis due to lockdown plausibly explain these associations, we may not be able to rule out the possibility of other UVB-induced mediators—such as nitric oxide 8,10,54. While we acknowledge there may be confounding factors posing challenges to our analysis, we used statistical methods to account for all time-constant and various time-varying factors as much as possible. We also acknowledge that UVB exposure may not substantially increase the vitamin D synthesis of specific categories of people, such as those wearing cultural protective clothing due to lower exposure to sunlight15 and those who are elderly due to less efficient skin synthesis55. Although we do not model these factors explicitly, our fixed-effects model accounts for most of these time-constant confounding factors.

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16641 20201005-weekly-epi-update-8.pdf PDF 2020 admin 25 Nov, 2021 17:59 1,020.40 Kb 4
16640 Lockdowns 1.jpg admin 25 Nov, 2021 15:31 112.03 Kb 103
16639 Lockdowns UV_compressed.pdf PDF 2021 admin 25 Nov, 2021 15:30 333.96 Kb 4
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