COVID-19 and Vitamin-D – NICE; Unthinking discrimination against BAME, Elderly and Obese? Affirmative-action needed to mitigate D deficiency, in high-COVID-risk groups.
In response to the comments of Dr Paul Crisp, Director of Nice, https://www.bmj.com/content/369/bmj.m2475/rr-8:
Multiple preprints suggest vitamin D deficiency factors in COVID-19 severity and mortality risk in BAME Persons, Elderly and Obese, COVID-19 patients. Vitamin D is a steroid hormone family (cheap, well-researched, natural, with limited side-effects, and a million-year evolutionary efficacy and safety-history), sharing many VDR (vitamin D receptor) pathways with Dexamethasone (a useful pharmaceutical steroid, 60 years old but not part of our evolutionary history, with a long list of potential side effects). Given VDR commonalities with Dexamethasone; immune biology, and wider emerging evidence; it might logically be expected vitamin D, like Dexamethasone, will likely, reduce immediate impact of COVID-10 severity and mortality. Vitamin D may further have longer term beneficial effects – longer term outcomes of Dexamethasone in COVID-19 have yet to be announced.
Thus, did NICE/NHS/PHE, our health guardians, in the fog and darkness of COVID-19, leave their ‘pandemic-act-decisively’ hat in the dexamethasone draw, when considering the needs:
- to test COVID-19 patients for vitamin D deficiency;
- to widen clinical recommendations for clinical testing;
- and or increase provision for automatic higher vitamin D repletion dosing;
thus ensuring better repletion of groups most at risk of Vitamin D deficiency.
This hesitancy ironically manifests, despite Vitamin D deficiency disease being a recognised, NICE defined, clinical condition; with NICE advice on; testing, repletion, and wider parameters. https://cks.nice.org.uk/vitamin-d-deficiency-in-adults-treatment-and-pre...
Within this framework, it is NICE, who delineates the very narrow parameters within which NHS clinical practitioners may test, in the terms;
- “Only test vitamin D status if someone has symptoms of deficiency or is at very high risk”;
- recommended supplementation is limited to RNI, unless the patient is deficient (which requires a test – hence the catch-22).
Thus, perversely, UK Doctors are discouraged from testing, and or sufficiently supplementing, those at greatest risk of both D-deficiency and COVID-19 mortality, namely; BAME Persons, Elderly, Obese, the Institutionalised, and Hospitalised; with their higher D repletion requirements – confusing / limiting the capacity of Doctors to address vitamin D deficiency in those that are most in need.
NICE unquestionably has authority and capacity to swiftly widen the groups who may be tested for vitamin D levels; and/or facilitate GPs administering, without testing, higher vitamin-D-boluses to all patients at medium-risk of deficiency (BAME, Elderly, Obese, Pregnant et al.).
As below, Australia tests more widely; and New Zealand recommends routine administration of 50,000iu per month; for medium-risk patients.
In contrast to the more visionary pragmatic Antipodean approach, NICE/SACN/PHE have arguably failed to address, with sufficient granularity, the niche-needs of minority groups, BAME, Elderly and Obese Persons, relying instead on generalised-population-based statistics. COVID mortality and infection rates are interestingly lower in the Antipodes, and a recent Australian spike has occurred in a complex with a high minority ethic populous.
NICE, by their failure to decisively address, both; the long-standing-high-risk of vitamin D deficiency; and likely related increased COVID-19 mortality rates, in these groups, arguably sadly open themselves to criticisms of discrimination by; Ethnicity, Age, Fat-mass, Institutionalised and Hospitalised Status, as well as failure to act D-decisively in a pandemic, based on likely benefits v harms.
A recommendation by NICE to vitamin D test COVID-19 Patients in hospitals and care homes, would have both; helped address D deficiencies in COVID-mortality-at-risk-group patients; and also provided valuable population data, including as to D status of the most COVID-mortality vulnerable; namely BAME Persons including those of African Americans origin, Elderly, Obese and Hospitalised– thus further and usefully informing public health policy.
A wider and a final search before NICE publication on 29th June, would have revealed omitted preprints, which together suggest a strong direction of emerging research; reflected in approximately 12 preprints including one in England (134 COVID-19+ patients), and more widely a German paper looked at D and respiratory function. Preprints were relatively easily found; as many were listed in the BMJ Rapid Response Letter dated 25th June 2020. https://www.bmj.com/content/369/bmj.m2475/rr-1
Subsequent known studies include; Cincinnati (689 Covid-19+ patients); Israel (14,832; 7087 COVID-19+ patients), and a military hospital in Brazil (172 COVID-19+ patients). Two of the original seven are no longer available; one of them following the sad death of the lead, Prabowo Raharusun GP, whilst working on the COVID-19 front-line.
A late NICE addendum would have allowed their listing/consideration on 29th June, in final summary conclusions. Adjustment for factors impacted by vitamin D such as hypertension, cardiovascular disease and obesity are complex, with limited value if not suitably nuanced. Hill criteria offer an alternative assessment protocol.
Is it not time for pandemic-urgent recognition of the need for vitamin-D-clinical-sufficiency equality for all, including BAME Persons, the Elderly and Obese.
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Competing interests: No competing interests