Covid-19: Continued outbreaks in care homes risk extending pandemic, say expertsBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2530 (Published 24 June 2020) Cite this as: BMJ 2020;369:m2530
All rapid responses
As discussed in BMJ and elsewhere, COVID-19 case and death rates in care homes are high and are extending the pandemic 1. The primary reasons are that the residents are generally elderly and in poor health and in close proximity to each other. Another important reason is thought to be that residents and care givers in nursing homes tend to be vitamin D deficient and those with vitamin D deficiency in nursing homes have higher mortality rates 2.
There is mounting evidence that vitamin D deficiency is an important risk factor for COVID-19 incidence rates. An observational study based on 212 COVID-19 patients from three hospitals in southern Asian countries found that serum 25-hydroxyvitamin D [25(OH)D] concentration was inversely associated with severity of COVID-19: those with mild infection (mean concentration of 78 nmol/l) had an odds ratio for mortality of 0.05 (P = <0.001) compared to those with critical infections who had a mean value of 43 nmol/l3.
The mechanisms whereby vitamin D reduces COVID-19 risks include reducing survival of SARS-CoV-2 virus and reducing the cytokine storm that causes much of the damage 4. While the role of vitamin D in reducing risk and severity of COVID-19 has not been confirmed by randomized clinical trials, a recent review based on a large body of evidence for COVID-19 and other pandemic respiratory tract infections concluded that the evidence supported a causal link between vitamin D deficiency and risk of COVID-19 5. In addition, a recent consensus statement signed by 21 mostly vitamin D researchers from the UK endorsed vitamin D supplementation to reduce risk of COVID-19 in accordance with government recommendations, i.e., 400 IU/d in the UK and 600 IU/d for the U.S. (800 IU/d for >70 years) and the European Union 6. As those recommendations were based primarily on the role of vitamin D for bone health and are inconsistent with recent findings for COVID-19 severity 3, we consider them too low.
To reduce COVID-19 risks in nursing and care-homes, and elsewhere, we recommended that vitamin D3 supplementation be used to increase 25(OH)D concentration to >75 nmol/l or, for more protection, >100 nmol/l. Doing this will also have important benefits with respect to chronic conditions and mortality rates 7. For those who have not been supplementing with vitamin D3, taking 25,000 IU/d vitamin D3 for several days could fairly quickly increase 25(OH)D concentrations, then followed with perhaps 4000 IU/d 8. Since vitamin D uses magnesium in changing metabolites 9, it is also recommended that people take perhaps 400 mg/d magnesium.
Other supplements also help maintain a well-functioning immune system including vitamins A, B6, B12, C, D, E, and folate; trace elements, including zinc, iron, selenium, magnesium, and copper; and the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid 10.
While this letter is directed at those in care and nursing homes, the recommendations are considered appropriate for all groups that have elevated risk for COVID-19: the elderly those with chronic health conditions; first responders; those who come in contact with many customers at work; those with dark skin living at high latitudes; vegans and vegetarians; who do not obtain much vitamin D from food; the obese; those living or working in crowded conditions such as in prisons, meat-packing plants, and favelas.
1. Griffin S. Covid-19: Continued outbreaks in care homes risk extending pandemic, say experts. BMJ 2020;369:m2530. doi: 10.1136/bmj.m2530
2. Samefors M, Ostgren CJ, Molstad S, et al. Vitamin D deficiency in elderly people in Swedish nursing homes is associated with increased mortality. Eur J Endocrinol 2014;170(5):667-75. doi: 10.1530/EJE-13-0855
3. Alipio MM. Vitamin D Supplementation Could Possibly Improve Clinical Outcomes of Patients Infected with Coronavirus-2019 (COVID-2019), 2020.
4. Grant WB, Lahore H, McDonnell SL, et al. Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients 2020;12(4):E988. doi: 10.3390/nu12040988
5. Davies G, Garami AR, Byers J. Evidence Supports a Causal Model for Vitamin D in COVID-19 Outcomes. MedRxiv 2020 doi: 10.1101/2020.05.01.20087965 [published Online First: 13 June 2020]
6. Lanham-New SA, Webb AR, Cashman KD, et al. Vitamin D and SARS-CoV-2 virus/COVID-19 disease. BMJ Nutrition, Prevention & Health 2020:5. doi: 10.1136/ bmjnph-2020-000089 [published Online First: May 2020]
7. Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality-a review of recent evidence. Autoimmun Rev 2013;12(10):976-89. doi: 10.1016/j.autrev.2013.02.004
8. Grant WB, Baggerly CA, Lahore H. Reply: "Vitamin D Supplementation in Influenza and COVID-19 Infections. Comment on: Evidence That Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths Nutrients 2020, 12(4), 988". Nutrients 2020;12(6):1620. doi: 10.3390/nu12061620
9. Dai Q, Zhu X, Manson JE, et al. Magnesium status and supplementation influence vitamin D status and metabolism: results from a randomized trial. Am J Clin Nutr 2018;108(6):1249-58. doi: 10.1093/ajcn/nqy274
10. Calder PC, Carr AC, Gombart AF, et al. Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections. Nutrients 2020;12(4):1181. doi: 10.3390/nu12041181
Competing interests: WBG receives funding from Bio-Tech Pharmacal, Inc. (Fayetteville, AR). CAB (GrassrootsHealth) works with various supplement suppliers to test the efficacy of their products in various custom projects. These suppliers may be listed as ’Sponsors’ of GrassrootsHealth. The other authors have no conflicts of interest to declare.