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Vitamin D: Covid-19

Volume 687: debated on Thursday 14 January 2021

Motion made, and Question proposed, That this House do now adjourn.—(Michael Tomlinson.)

May I start by giving my thanks to the hon. Member for Ealing Central and Acton (Dr Huq) who cannot be with us today, but who is a fantastic ally of mine in this campaign to help protect our public?

Today, the nation is facing the second peak in the worst health crisis in living memory. To date, nearly 85,000 people have died. In November, the death rate was 175 fatalities per million, in December that figure was 222, and it looks as though January will be more than 324. To deal with this catastrophe, the Government are reluctantly instituting tough lockdowns and considering even tougher ones. Whether these measures work is disputed by some, but there is no doubt that they are incredibly costly—in economic damage, in individual freedom, in mental health, and even in lives lost to other causes.

As the death rate per million climbs month by month, from 175 in November to 324 now, the strategy certainly is not working as well as we would hope. Compare that with the province of Andalusia, a Spanish province of more than 8 million people. It started in November with a situation worse than ours—189 deaths per million as against 175—but which cut its death rate by at least two thirds while ours was doubling. That reduction, from between 50 and 70 deaths a day in November to between five and 15 deaths a day currently, started immediately after it initiated a programme of issuing calcifediol, the fast-acting high potency form of vitamin D, to at risk groups including care home residents.

The first thing that I will ask the Minister to do—not today obviously, but afterwards—is to look closely at that policy experiment and see whether vitamin D was the key to what is a spectacular success in cutting death rates by anybody’s measure. I believe that the Government in Madrid are reviewing it. So should we.

For decades, researchers and medical professionals have been warning that there is a pandemic in vitamin D deficiency, with more than 1 billion people worldwide being vitamin D deficient. The warning bells for this ignored pandemic had been ringing long before the World Health Organisation declared the outbreak of covid-19 as an official pandemic on 11 March last year. Those warnings should have been especially loud in the UK, as our vitamin deficiency levels have been described in a recent research study as “alarmingly high.”

Does the right hon. Gentleman agree that, given that children have been precluded, for very obvious reasons, from taking the vaccine, we need to be proactive in building up their immune system? Will he join me in asking the Minister and the Health and Social Care Department to work with the Education Department to provide free vitamin D to every school-age child? I have asked the Minister in Northern Ireland to do the very same.

It is an excellent idea and I do join him in that request.

On the question of medical education, it has long been understood that vitamin D plays a critical role in calcium uptake and the prevention of diseases such as rickets and osteoporosis. That was what was thought to be its main effect. Since1983, there has been a large amount of research demonstrating its critical involvement in the body’s immune system. Many of the mechanisms involved are now very well understood. By 2017, it had been clearly shown in a number of randomised clinical trials that vitamin D deficiency was a very significant issue in acute respiratory disorders such as flu, colds, pneumonia—the lot—and correcting the deficiency with supplementation could reduce the severity of symptoms by as much as 70%. This and other research showed that vitamin D had a critical role in the activation of both the innate and the adaptive immune systems and in modulating some of their responses, most notably the now infamous cytokine storms. Deficiency in vitamin D led to compromised immune systems and, as a result, susceptibility to a number of diseases, most particularly respiratory diseases but of course also covid-19. Despite this evidence to suggest that vitamin D has wider health benefits than just bone health, and despite our particularly exposed situation in the UK, our public health bodies have done little to correct this problem.

At the beginning of the covid-19 crisis, several well-respected research teams noticed a high correspondence between low vitamin D levels—deficiency—in the blood and severity of covid-19 symptoms in patients. Early evidence suggested a strong link between the two, with studies showing that 40% of patients who suffered severe covid-19 outcomes were vitamin D deficient compared with 4% of those with sufficient levels of vitamin D. Moreover, mortality rates of vitamin D deficient patients were dramatically higher than for patients who had sufficient levels of vitamin D. These were correlational studies, so they were not proof of causality, but they were massively indicative given the prior evidence of the importance of vitamin D to the immune system. So this was startling evidence.

Therefore, in early May last year, I wrote to the Health Secretary calling on the Government to urgently review the available evidence to assess the role that vitamin D could play in helping us to combat this dreaded virus. The Health Secretary, quite reasonably, handed this work to his health advisers and ordered them to undertake a rapid review of the evidence. The National Institute for Health and Care Excellence attempted to analyse the statistical data and came back unconvinced. The problem is that correlation is not a proof of cause and effect, and a correlation, albeit a strong one, was all that we had at that point. In effect, NICE said that more data was necessary. One would think that at this point it would have initiated a large, well-designed random control trial to pin down the question: is vitamin D a causal factor in bad covid outcomes in terms of morbidity and mortality? After all, it is an incredibly serious disease and this is a very cheap and safe treatment. Not only did it not do this, but two applications for funding to carry out random control trials were turned down. Since then, more general global evidence in many other countries has grown in strength, which makes the inaction all the more questionable. Several studies have been published showing how low vitamin D levels lead to poorer outcomes for covid-19 victims.

In September 2020, the results of the world’s first randomised control trial—the gold standard of medical research—on vitamin D and covid-19 were published. The trial, conducted in the south of Spain at a hospital in Córdoba, involved 76 patients suffering from covid-19 sufficiently badly to have been hospitalised. Fifty of the patients were given vitamin D and the remaining 26 were not. Half of those not given vitamin D became so ill that they needed to be put in intensive care. By comparison, only one person of the 50 given vitamin D required ICU admission—just one. To put it another way, the use of vitamin D seemed to reduce a patient’s risk of needing intensive care twenty-fivefold.

Other studies have shown, at a statistically significant level, large reductions in mortality too. There was an experimental study conducted at a nursing home in France with 66 participants. The outcome of that study was that taking regular vitamin D supplements was associated with less severe covid and a better survival rate. Evidence from the United Memorial Medical Center and Sentara Norfolk General Hospital, both in the US, showed that they could get a more than 75% absolute risk-of-death reduction and reduction in mortality when treating patients with a cocktail of treatments including vitamin D. Researchers at Eastern Virginia Medical School who designed the protocol estimate that if their approach, including vitamin D-to-patient management, had been widely implemented at the start of the pandemic, it could have saved many, many thousands of lives.

The results of these studies are stark and clear-cut, and what was originally dismissed in some quarters is now backed by leading medics around the globe. Richard Carmona, the 17th surgeon-general of the United States, has said:

“The response to the pandemic…should include an effort to aggressively eliminate what is becoming apparent as a morbidity and mortality risk factor in COVID-19—vitamin D deficiency.”

Dr Carmona pointed out that the classical criteria for dealing with correlation evidence was, ironically, drawn up in this country by the great British physicians Sir Austin Bradford Hill and Sir Richard Doll in their study of smoking and lung cancer. They deduced that it was possible to use correlational data to show causality if certain other conditions could be shown: consistency of evidence, specificity of evidence, dose responsiveness and what they called temporality, which basically means that what happens first is the cause and what happens second is the effect—it is fairly obvious when you put it in English.

The simple fact is that we can show that all the Bradford Hill criteria are met for vitamin D and covid-19 if we look at the many separate individually small but collectively persuasive studies. Every single one of the criteria can be seen to be met. That is presumably why Dr Anthony Fauci, famously the head of the US Coronavirus Task Force—a difficult job at the time—has said:

“There is good evidence that if you have a low vitamin D level… you have more of a propensity to get infected”.

These are serious voices that are now backed up by serious evidence.

To give the Government proper credit, they have instigated the provision of a supplement free of charge to the clinically extremely vulnerable in care homes. However, if supplementation is to have any material effect, the dosage has to be sufficient to correct the existing deficiency. Sadly, with the Government’s programme for the clinically extremely vulnerable, the supplementation falls far short of this. The Government are providing supplements of 400 international units, or IU. That is in line with what the national health service currently recommends to tackle issues surrounding bone health. By contrast, the American health authorities recommend 600 IU to 800 IU depending on age. The latest research from the Royal College of Physicians recommends that health authorities should urgently recommend a higher supplementation of 800 IU to 1,000 IU a day, which would more than double the current daily recommended dose of vitamin D.

However, even that dose—based on bone health—is not high enough to provide the additional benefits and protect against respiratory disorders such as covid-19 for those with existing deficiencies; it must be much, much higher. We are not aiming to protect elderly people in care homes from rickets. We are aiming to protect them from a lethal disease, which is a very different issue.

The vitamin is safe in quite high doses. In the summer months, a person could sunbathe for 30 minutes and get the equivalent of 20,000 IU—much more than would be taken in a daily dose. All the modern toxicological evidence indicates that if there are any deleterious effects at all, they do not happen until a much higher dose than 20,000 IU. Even the NHS, which is very cautious on this, accepts that a dosage of 4,000 IU a day is perfectly safe; it says so on its website. What is needed to provide adequate protection against covid-19 is a significantly higher dose of up to 4,000 IU per day, particularly for those vulnerable groups that tend to be deficient in the vitamin—namely, the elderly, ethnic minorities and those suffering from a number of medical conditions.

Providing the supplement to the clinically extremely vulnerable in care homes is a small step in the right direction. However, it is a drop in the ocean compared with the action the Government should be taking overall. There needs to be a wider scheme providing supplements to all at-risk populations, including the elderly, the obese, minority ethnic groups, diabetics and people with high blood pressure. That would be a tiny cost compared with other health initiatives. A year’s supply of a daily dose is likely to cost about £15 a person, so allocating it to the identified risk groups would amount to £45 million. Allocating it to those groups plus every ethnic minority citizen would cost about £200 million, and to every clinically obese person and at-risk people in other categories would cost a little more. However, those figures could be halved if the risk is more severe during the winter months and we just gave the dose then. The benefits would be enormous. That cost is a mere rounding error when we measure it against the cost of not defeating the pandemic or the cost of a lockdown.

It is by no means a coincidence that the United Kingdom has one of the worst mortality rates in the world. After all, we have one of the worst rates of vitamin D deficiency in the world—about 40% of the population—and with that, very high levels of people with compromised immune systems. However, Public Health England continues to refuse to acknowledge the growing evidence linking vitamin D deficiency and poorer covid-19 outcomes, and for this, we are now paying the price.

Vitamin D could be one of the tools that helps turn the tide in the fight against this terrible virus. Vaccines, of course, are now being rolled out, but it will still take some time to reach levels sufficient that lockdowns are no longer needed. The Government are doing a great job on vaccines, but there are limits to what they can do, and unlike the general effect of vitamin D sufficiency on the immune system, vaccines are very specific. If a person has a specific mutation, the vaccine can be rendered obsolete; that is not true of vitamin D. In the meantime, vitamin D supplements could be provided to all at-risk groups more quickly, and at a lower cost.

As I said at the beginning of my speech, the UK has now had nearly 85,000 covid deaths. It is long past the point where we try anything with even a marginal chance of success to prevent those deaths rising even higher. Well, vitamin D has much more than a marginal chance of success: we now have good reason to believe that vitamin D supplementation will help reduce mortality from covid-19 and cut susceptibility to infection. It will save lives, improve population immunity, and help reduce the medical and economic impact as we continue the universal roll-out of vaccines.

There is now no reason not to act. After all, in the Secretary of State’s own words, supplementation has “no downsides”—he was right. The surgeon general whom I quoted earlier said that we should not let covid-19 patients die with vitamin D deficiency while we “wait for perfect evidence”. Vitamin D is cheap; it is safe; it has many other proven health benefits; and, as the Government of Andalucía have shown, it could be a dramatically effective weapon in our fight against covid. There is no more time to waste. The time to act is now, Minister.

I am extremely grateful to my right hon. Friend the Member for Haltemprice and Howden (Mr Davis) for having secured this debate, as well as to the hon. Member for Strangford (Jim Shannon); it would not be an Adjournment debate if he did not play his part.

As we have always said, the Government consistently review the latest data and information on covid-19 as it emerges. This, of course, includes the progress there has been in treatments for those suffering with the virus, as well as preventive measures. I would like to express my thanks to health and care workers and to the scientific community, whose dedication and hard work has made this possible, and I am sure right hon. and hon. Members from across the House will join me in doing so. Over the past months, there have been reports about vitamin D potentially reducing the risk of coronavirus, and I am aware of colleagues’ interest in the relationship between vitamin D and covid-19. I welcome the opportunity to discuss it today because, as my right hon. Friend says, nothing should be taken off the table, and we should be constantly vigilant when it comes to new science and information.

Several nutrients are involved in the normal functioning of the immune system; however, there is currently insufficient evidence that taking vitamin D will mitigate the effects of covid-19. In collaboration with Public Health England and the scientific advisory community on nutrition, NICE has published a rapid guideline on vitamin D in relation to covid-19, which my right hon. Friend mentioned. That data was reviewed by an expert panel and included the best available scientific advice published so far, including both randomised control trials and observational trials. That expert panel supported current Government advice, and the recommendation for everyone to take a 10 microgram vitamin D supplement throughout autumn and winter. However, it concluded that there is not currently enough evidence to support taking vitamin D in order to help, or treat, covid-19. There are still significant gaps in the current evidence, and studies to date have not reached the high level of data quality required to revise the guidance.

I heard what my right hon. Friend said about not wasting time, but as he mentioned, the Spanish study to which he alluded only included 76 participants. The smaller the sample group, the more challenging it can be to draw conclusions about the effect. We are also dealing with very poorly people, with multiple different factors affecting how they are responding and what they are responding to, so it is important to ensure that we can rely on that data. Indeed, there was a good double-blind trial before Christmas that showed no effect. However, there is a large-scale trial currently at Queen Mary University of London. I hope that it will give us some good clarity when it reports later in the year.

The current evidence base is mixed, and dominated by studies that are not always of great quality, with substantial concerns about bias and confounding. At the moment, they are unable to demonstrate that causal relationship between vitamin D and covid-19, because many risk factors for severe covid-19 outcomes are the same as for low vitamin D status. Due to the lack of reliable evidence, the NICE guideline recommends that more research is conducted. Government guidance continues to stress the use of high-quality randomised controlled trials in future studies. There are 70 trials under way in the UK and internationally, including some very high-quality ones that will answer key questions from NICE, Public Health England and the Scientific Advisory Committee on Nutrition, and they are monitoring this new evidence. My right hon. Friend asked for my assurance that we are doing that, and I can give him that.

The long-standing Government advice is that, between October and early March, everyone should take a supplement containing 10 micrograms, or 400 international units, of vitamin D a day. Vitamin D helps to regulate the amount of calcium and phosphate in the body, and protects bone and muscle health. In April and autumn 2020, PHE reiterated its advice. It also ran a marketing campaign throughout December 2020. This had a specific focus on the communities mentioned by my right hon. Friend, in particular the BAME community, for whom vitamin D supplementation is very important. PHE advice to continue taking vitamin D supplements is important for those who are shielding, care home residents and prisoners, as well as for those who choose to cover most of their skin when outdoors. As he said, BAME individuals have a greater risk of not having high enough levels of vitamin D, and are advised to take a supplement all year round.

We are actively supporting the uptake of PHE’s recommendations to ensure that those who need vitamin D supplementation receive it. The Government are providing a free four-month supply of 10 microgram vitamin D supplements to all adults on the clinically extremely vulnerable list, going far beyond care home residents who have opted in, residents in residential and nursing care homes in England, and the prison population; Her Majesty’s Prison and Probation Service have made supplements available across England and Wales. Through this commitment, this winter we have offered 2.7 million eligible people in England free vitamin D supplements, and to further drive uptake we have extended the registration period to 21 February so that even more people can benefit.

The Government have prioritised groups who were asked to stay indoors more than usual in the spring and summer due to national restrictions. In addition, recipients of the Healthy Start scheme are also offered access to vitamin supplements by the Government, and of course GPs and pharmacists may be approached for general advice on taking vitamin D. However, we do not expect this measure to place any additional burden on either group, as they are under some pressure during the current pandemic. Guidance can be found online and we encourage individuals to buy 10 microgram vitamin D supplements, which are easily available from supermarkets, chemists, and health food shops.

We must keep looking at the evidence, and as research into the impact of vitamin D on covid-19 continues, we will continue to monitor it as it is published in real time. We have committed to keep this under review. PHE, the Scientific Advisory Committee on Nutrition and NICE will update advice if and when necessary. Of course, I welcome any further studies into this emerging area.

I know my right hon. Friend wants us to move at pace. He embarks on everything he does with enthusiasm and vigour. However, I am sure he will agree that we are nudging along and some progress has been made. Future decisions should and must be based on robust evidence.

Question put and agreed to.

House adjourned.