Re: Preventing a covid-19 pandemic - COVID-19: Vitamin D deficiency; and, death rates; are both disproportionately higher in elderly Italians, Spanish, Swedish Somali, and African Americans? A connection? Research urgently required! BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m810 (Published 28 February 2020)
It is posited by contributors [1, 2, 3, 4, 5] to BMJ, ‘Preventing a covid-19 pandemic’, others, [6, 7, 8] and myself,  that vitamin D, and particularly vitamin D deficiency, is a likely factor in the progression, and/ or severity, and/ or mortality of COVID-19; and also may present clinical treatment opportunities.
My preprint, ‘Vitamin D deficiency: a factor in COVID-19, progression, severity and mortality? – An urgent call for research’,  posits, greater vitamin D deficiency <25nmol/L in southern (E.g. Spain and Italy), than northern European Countries (E.g. Germany, Norway, Finland, Iceland), may help account for differentials, in mortality rates per million. Consistent with this, Northern Europeans have higher vitamin D food intakes, food fortification, and supplement more. This is an easily testable posit.
Northerly resident; Europeans with darker skins; BAME, and African Americans; as well as more southerly elderly Spanish and Italians; are often vitamin D deficient. IF, vitamin D deficiency, increases the risk of COVID-19 related; infection, hospitalisation and mortality; one would expect, and indeed sees, higher COVID-19 hospitalisation and mortality, in; dark-skinned (Fitzpatrick scale) northerly residents; those with dress codes that inhibit sunlight; and generally in groups likely to include the ‘D’ deficient.
Whilst data is still sparse, it supports the above contention; albeit lack of distancing, and vitamin D deficiency, may both be contributing factors; for example: “40 % of the reported COVID-19 related deaths occurring in Stockholm involve the Somali diaspora communities”; yet they only represent 0.84% of the population] [10, 11, 12, 13] Data clearly shows, Somalis, and wider immigrant groups, are D deficient, for example, “Vitamin D deficiency ( < 25 nmol/l) was found in 73% of the Somali women and in 1% of the controls” [14, 15, 16]
In respect of African Americans, a headline, April 3rd, 2020, states, ‘Early Data Shows African Americans Have Contracted and Died of Coronavirus at an Alarming Rate  “In Chicago, 70% of COVID-19 Deaths Are Black,”  The review, APHA ‘Call for Education and Research Into Vitamin D Deficiency/Insufficiency’, in 2008, noted, “84% of African American men and women (over 65) were vitamin D deficient.” [19, 20, 21] (‘D’ deficiency definitions vary).
In contrast, in continental Africa, whilst Vitamin D deficiency exists, it does not appear to be as widespread as in the United States: “one in five people living in Africa had a low 25(OH)D concentration with use of a less than 30 nmol/L.”  COVID-19 data for Somalia is limited. Tests are done externally: current data; 7 cases, 1 recovered, no deaths.  The first recorded case was confirmed on the 16th of March. Twenty volunteer doctors from Somali National University went to Italy to help fight COVID-19 there. [24, 25] Case numbers in wider Africa are currently relatively low, compared to the most infected countries, but arguably there is insufficient data, or certainty, as to initial infection dates, to, at this point, even postulate as to future COVID-19 infection, or mortality rates, in Africa. 
Differences appear to exist in the metabolism of Vitamin D; ‘The D paradox’;  between Caucasians and African Americans, particularly in terms of bone density. However, the metabolism of vitamin D is complex, and pathways impacting COVID-19 likely differ from those regulating bone densities.
The COVID-19 mortality rate, has very sadly, been high in Italy (15,887 as at 5th April 2020).  A rapid response to the BMJ titled ‘Re: Preventing a covid-19 pandemic Can high prevalence of severe hypovitaminosis D play a role in the high impact of Covid infection in Italy? ’ notes, “700 women aged 60-80 yrs in Italy had values of 25OH vitamin D lower than 5 ng/ml in 27% of the women and lower than 12 ng/ml in as many as 76%.” 
BAME (Black, Asian, Minority Ethnic) persons in the United Kingdom, may be more susceptible. A UK study of 2,249 patients by the ‘Intensive Care National Audit and Research Centre’, noted “Despite making up just 13 per cent of the UK population, a third of patients who fall critically ill with COVID-19 are from black, Asian or minority ethnic (BME) groups.”  Further, sadly, 6 out of 8, UK COVID-19 medical staff deaths, were British Muslims. Hasidic Jews in Israel may also be at higher COVID-19 risk, due to failure to isolate and/ or greater risk of vitamin D deficiency.[33, 34]
Arguably it is urgent, that research is done, to determine if vitamin D deficiency factors in COVID-19, infection, progression, severity and mortality. Vitamin D blood spot tests are cheap. Patient records have to be maintained in any event. The additional work, and risk burden, in taking vitamin D measurements are limited. However, the reward could be very significant, even a ‘game changer’.
Further, any determination that vitamin D factors in COVID-19, incidence progression and outcome, would point to the likelihood of COVID-19 following a seasonal pattern in populations, which would require factoring into determination of Governmental COVID-19 forward planning policies; mortality risk modelling; social distancing polices; and population vitamin D optimisation, including access to outside spaces, to facilitate sensible, ethnicity appropriate, exposure to UVB in sunlight; and/ or free ‘D’ supplementation, at least for the most vulnerable and financially insecure.
COVID-19 studies might comprise:
- Test all COVID-19 patients in hospital/s at a given point in time for Vit D, follow, and report results.
- Take finger prick samples at the same time as COVID-19 test – follow through with laboratory vitamin D tests on the samples of all positives, and an equal number of controls; report results.
- A study using Vit D clinically – test for low vit D – where low supplement with vitamin D3, and/ or as an alternative to above, try a 1,25-active form;  report results.
Vitamin D, could usefully be immediately incorporated into wider clinical nutritional COVID-19 protocols, [36, 37] but, to better understand the role of vitamin D in COVID-19; for the formulation of; treatment, prevention, and wider, policies; the above studies would still be urgently required.
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