COVID-19 Vitamin D Overview - Sunil video and transcript - Dec 8, 2020

Emerging role of vitamin D in the prevention of COVID-19 by Prof. Sunil Wimalawansa 110 minute
Dr. Wimalawansa has routinely given 200,000 IU Vitamin D loading dose to all of his patients since 2000

A few of the slides

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Transcript

0:00:06.7 Speaker 1: Hi, good evening everybody. I'm Chamila Jayasinghe. On behalf of the College of Biochemists of Sri Lanka, I welcome you today to our monthly webinar series. The College of Biochemists serves as academic and educational headquarters for biochemists and molecular biologists in Sri Lanka. And it is the official country representative to the Federation of Asia and Oceanian Biochemists and Molecular Biologists, the FAOBMB. The College serves as a platform bringing together biochemists and molecular biologists in Sri Lanka and abroad in the exchange of scientific ideas and knowledge, as well as training. So today's topic Is the emerging role of the vitamin D in the prevention of COVID-19 by Dr. Sunil Wimalawansa, Professor of medicine, endocrinology and nutrition at the Cardio Metabolic and Endocrine Institute, New Jersey, USA. I'd like to invite my colleague, Dr. Sanath Mahawithanage to introduce the speaker to you today.

0:01:13.7 Speaker 2: Thank you very much Dr. Chamila. Dr. Wimalawansa MD, PhD, MBA, FACP, FACE, FRCP, FRCPath and DSc. He's a Professor of Medicine, Endocrinology and Nutrition. He started his career as a lecturer in biochemistry at the University of Peradeniya under the mentorship of late Professor PW Vikrmaye. Later, he proceeded to UK for his higher studies. Professor Wimalawansa has held various positions in various organizations. He was a consultant to the International Atomic Energy Authority, and also served as a professor of physiology and Integrative Biology and pharmacology at the Graduate School of Biomedical Sciences in New Jersey to name a few. He was awarded several investigate awards such as the annual Dr. Boy Frame Award for Clinical Excellence in Metabolic bone diseases. His contribution to the field of Life Sciences is remarkable. In 1984, he invented the use of intraoperative hormone essays to assist in endocrine surgical procedures, now used by thousands of endocrinologists, surgeons globally as the standard of care. This is just one example.

0:02:46.9 SM: More than that he is a all around. He is the first Sri Lankan to climb Himalayas, a retired Air Force squadron leader and a philanthropist. He established his foundation, or Wimalawansa Foundation to help poor people affected by CKDu, and one of the leading researchers in that prospective. Among the number of books that he has written and published, one of the books that I like most is titled, All You Need to Know About Vitamin D. I think he's one of the most qualified individuals scientist to talk about this field. Over to you, Professor Sunil Wimalawansa.

0:03:36.5 SW: Hello, thank you, Dr. Jayasinghe and Mahawithanage for inviting me to give this presentation on emerging role of vitamin D in the prevention of COVID. Here, I'm going to discuss the basic aspects of the definition of vitamin D, epidemiology and basic biochemistry with reference to generation, and D2, also D3 and consequences of hypovitaminosis D. The most part of my presentation will be focusing on the deficiency and relationship to COVID-19 and its clinical outcomes. In this presentation, I do not have any conflict of interest. The book mentioned by Dr. Mahawithanage is on Vitamin D: All You Want to Know, and the second one, The Biology, Physiology, and Pharmacology to Vitamin D will be coming sometimes next year.

0:04:35.8 SW: So this is the book Dr. Mahawithanage mentioned. Importantly, vitamin D, or in North America it's called vitamin D is an essential hormone. Without it, humans cannot survive. There are two basic metabolites of vitamin D, D2, and D3 of physiological concern. The D2 is a plant source whereas the D3 is animal source. There are two major differences of D2 and D3. Firstly, D2 has a shorter half life compared to D3 and in D2, there is a double bond between C22 and 23 with methyl group on C24. So, for a clinical point of view, D3 is the right or the proper human variety of D3 to be prescribed.

0:05:39.5 SW: So, again the difference between the D2 and D3 is the half life, from a clinical point of view, thereby giving the same doses you can see D3 levels goes up quickly and maintain a longer period because of the half life is longer. So, D3 is the natural form for humans and indeed the preferred form for supplementation. So, D3 is essential for survival. In addition, the major portion of the D3 requirement is supposed to be maintained or made in our skin following exposure to ultraviolet B rays in sunshine. In fact, now, D3 deficiency is the most common vitamin D deficiency, but it's very easy to rectify and costs so little.

0:06:34.4 SW: So assessing the Vitamin D status, the measurement of serum 25 D hydroxy level is the only way forward. Do not measure 1,25-dihydroxy D, but measure if we need it, only 25-hydroxyvitamin D level. So let's look at the biochemistry, physiology and the pharmacology of vitamin D, again, related to today's presentation. Historically, humans have obtained vitamin D through skin exposure to ultraviolet B rays from the sun in this particular UVB exposure range. It converts the 7-Dehydrocholesterol in the skin into pre-Vitamin D, and through process called isomerization, and then pre-vitamin D will be converted to D3 before it's transferred or transportated through the binding to vitamin D binding protein into the liver.

0:07:38.8 SW: So in this diagram, I'm going to show you the generation of vitamin D from generating D3 from the skin, pre-vitamin D. Cholecalciferol is the human or the D3 version, and it converted to 25-hydroxyvitamin D in the liver, and further hydroxylated in the kidney's renal tubules into 1,25-dihydroxyvitamin D. This is the active hormonal form. It's also called Calcitriol and that one leads to physical effects or biological effects, following its binding to its receptor. Similarly, the dietary intake of vitamin D, mostly D2, follow the same pathway and lead to similar biological effects. Since this is a biochemistry forum, I'm going to discuss a little bit more in detail about the biochemistry and the conversion and how it affect these cellular function.

0:08:44.3 SW: The precursor of vitamin D3, here the calcitriol, is the calcidiol is called the 25-dihydroxyvitamin D. So it's activated into calcitriol in the renal tubules, and this is the one that has the hormonal action throughout the body. However, in target tissues, the intracellular generation of 1-alpha through hydroxylation into calcitriol is the most important pathway by the immune and the other system and the cells activated through intracellular regeneration of calcitriol. So this leads to paracrine and autocrine function, whereas the calcitriol generated in the renal tubules, it purely function as a endocrine hormone. So that's two different aspects of calcitriol. The most common mutual deficiency in the world now, Vitamin D, which has surpassed the iron deficiency and anemia. So it's very easy and economical to correct the vitamin D deficiency. The absence in the children can lead to rickets, the bowing bones, and in adults, it leads to osteomalacia or in Latin it's called softening of bone. The latter is also associated with neuromuscular incoordination, therefore increased falls, osteoporosis and fractures. Moreover, it also associated with many disorders, and I'm gonna summarize one in a couple of minutes later.

0:10:33.3 SW: For a biochemistry and physiology point of view, there are a major difference between the function or the absorption and the biological function of medications versus micronutrients. But you see in this green line, is the how the drugs or medication behave once they're administered through the oral route. As you see, it has a wider function of three orders of magnitude from here all the way to here, a larger area of functioning with a gradual increase in the level and the function is improved with that. This is in contrast to vitamin D, which is a threshold nutrient similar to iodine and B12. So this threshold nutrient has a totally different way of biologically acting. As you see, with reference to the vitamin D, it changed from 10 nanograms to 100 nanograms a mil, which is only one order of magnitude compared to a drug that has three orders of magnitude. So this narrow therapeutic range, you do develop or generate all the biological and physiological functions.

0:11:52.9 SW: If someone has adequate vitamin D level, giving further nutrients, similar with the iodine, B12, will not generate any additional beneficial effects. It's a flat curve. Whereas when you have the deficiency, giving even a small amount can make a difference in physiological functions. So I'm going to present you with several key or the fundamental issues that you need to be aware of related to vitamin D. One is the differences of tissue and body systems needing to get the activity to the maximum. So in this slide, I've summarized. The x-axis is the serum 25-hydroxyvitamin D level in nanograms a mil in the most of the slides. And on the right side, I'm showing the alleviation of, or improvement of disease condition. As you see, in mineralization or alleviation of rickets and osteomalacia, only need the 10-15 nanograms of vitamin D in circulation. It's very sensitive. But as the, for example, alleviation of cardiovascular diseases and reducing all cost mortality due to Vitamin D deficiency, you need a much higher level, in this case, almost four times higher, blood level of Vitamin D to overcome such disorder, so with reference to nutrient like Vitamin D, one dose does not fit everyone.

The cost of correction of Vitamin D deficiency is less than 0.001 of the cost of dealing with complication associated with Vitamin D

0:13:35.0 SW: It's dose-dependent, and for example, like all cumin diseases and cancer prevention, you need even higher level of Vitamin D in the circulation. Moreover, this therapy with Vitamin D or supplementation is highly cost-effective. So, yeah, I will summarize in one sentence. The cost of correction of Vitamin D deficiency is less than 0.001 of the cost of dealing with complication associated with Vitamin D, for example, management of diabetes and it's complication, obesity, metabolic syndrome, cancer or cardiovascular diseases.

0:14:17.9 SW: In general, the mentioned disorders will cost anything from $5000 to $15,000 per year per person in the United States, and the similar, but proportionately lower in other countries, nevertheless, you can see that the replacement of Vitamin D cost much, much less than that. Despite all this and the knowledge of over 60,000 research publication available in the internet in Science websites, vast majority of the population are still kept vitamin D deficient. So, let's look at the prevalence of Vitamin D insufficiency, at least, from where I used to work in USA, and especially in the nursing homes and disability centers, Vitamin D deficiency is amounting nearly 90% of their population. So you can see that this amount of Vitamin D deficiency, this is in spite of government mandated 400 units of Vitamin D given to every person in nursing homes and disability centers. So that kind of doses it's pediatrics and does not even touch in adult diseases.

0:15:42.4 SW: So the key reason for Vitamin D deficiency globally is lack of exposure or failure to exposure to sunlight, and in COVID cases, that has led to more than 60% or 70% of the deaths associated with this viral disease. For example, the deaths in nursing home residents could have been reduced by 70% by supplementing with Vitamin D in the range of 4000 to 5000 a day and this had been prevented. Unfortunately, very few places if at all they acted properly. The combination of advancing age, poor health, and comorbid conditions as mentioned like diabetes, hypertension, cardio-vascular disorders, and the Vitamin D deficiency is detrimental for the health and well-being of the elderly. So I'm gonna give examples to summarize the relationship between the low Vitamin D and multiple other disorders like diabetes, obesity and metabolic syndrome.

0:16:53.7 SW: So all of you are aware of these common set of conditions, starting with the metabolic syndrome, the recent derangement of hormonal and metabolic functions, it can lead to diabetes, hyperlipidemia, hypertension, obesity, and indeed insulin resistance. Similarly, the insulin-resistant diabetes, obesity can worsen the metabolic syndrome. However, most people doesn't understand, is that Vitamin D is underlying cause for worsening of most of these disorders and severity and complications. So all this can be minimized, not eliminated by correcting the Vitamin deficiency that would not cost anything more than $7 to $8 per person per year. So let's look at the evidence supporting a relationship between COVID-19 and Vitamin D. So that's a key part of our topic today.

0:18:00.7 SW: So what we're looking at is a causality of whether Vitamin D is related to COVID-19 and whether the death rates and complication are related to hypovitaminosis D. So in a person with COVID-19, for each standard deviation increase of serum Vitamin D level, the odds ratio of having a better outcome is increased by nearly 20 times, 20-fold not 20%. So similarly, the opposite also true, when there's a decrease of one standard deviation, it increase the probability of complication and deaths by closer to 20-fold. You can see that the sharper part of this curve, I showed by the threshold nutrient and the value of replacing this essential micronutrient. So in addition, the multiple observational data, I'm talking about a few hundred published reports or scientific data showing the positive association between Vitamin D status and COVID-19 outcomes. Now in addition, towards the end of my talk, I will go on to discuss very briefly, the hormonal system called renin-angiotensin system. So this is the one goes over-activated by the COVID-19 through indirect mechanism, which lead to massive production of cytokine, the chemicals in the body leading to inflammation, oxidation, and so called cytokine storm leading to respiratory disorders and death.

0:19:50.6 SW: So what are the evidence that vitamin D causality to COVID-19. There are only handful of clinical trials in this area published today, because this is during still the first year of the manifestation of COVID-19. But today there are at least 50 very large, statistically powered, randomized control studies are available, or they're ongoing and this data from these studies will be... Begin to available from December onwards. Meanwhile, the majority of people admitted to ICUs, Intensive Care Units, with COVID-19 are having severe hypovitaminosis D, especially the levels are less than 10 nanograms per mil, and by definition, it's a severe vitamin D deficiency. In addition, the higher incidence of COVID-19 related deaths occurring in the location where there's less sunshine, Northern latitude, so as a southern-most latitude during the wintertime, common feature is, these countries have a lower ultraviolet-B irradiance, therefore the people especially during the wintertime has the least amount of vitamin D, and half the population become severely vitamin D deficient. In this case, respiratory viruses as again, I will touch later, have higher chances of infecting people and causing complication and deaths, just as we what we saw with influenza over... In each year and through COVID-19 during the winter 2020, and similar thing is going to happen in 2021.

0:21:36.4 SW: And those with darker skin color, individual will have a disproportionately impact by COVID-19 mortality, especially if they're living in the temperate climatic countries like the UK and northern part of United States. So in addition, the both observational and randomized controlled studies published to date on COVID and vitamin D, reported significant inverse correlation of 24-hydroxyvitamin D level in the blood, and COVID-19 risk, severity and indeed, deaths. So, this important bit of information you need to remember, in general, when the person having less than 10 nanograms per mil of 24-hydroxyvitamin D, which by definition is severe hypovitaminosis D, the death rates are extremely high. In the interim, having less vitamin D, between 11 and 20 nanograms per mil have a severe disease, but they will recover. But as of those with moderate disease have a less complication. And those with the higher levels above 30, and the vast majority, I'm talking about more than 95% of them do not have any symptoms, they become asymptomatic, sometimes carrier of the disease as well.

0:23:09.1 SW: So those having the serum vitamin D concentration less than 12 ng/mL are likely to have a 14.7 times die from the disease once they get infected. In this study survival graph, we saw that the survival probability in the y-axis and the duration on the x-axis. So what you're looking at here is the study published from Germany which show that the 185 patients with the probability or the p-value is 0.001, certainly shows that the likelihood of dying from vitamin D concentration less than 12 ng/mL is significantly higher. So another way to looking at it, the European map showing the percentage of population who are less than 10 ng/mL. In the y-axis, when you're looking at it, the deaths per million from COVID-19. So all those countries with the higher percentage of people with the vitamin D deficiency has a very high death threat from vitamin D deficiency. This is another way of looking at vitamin D deficiency association with COVID-19.

0:24:29.6 SW: It has few, the key factors of biology and physiological vitamin D has forgotten and in fact many doesn't even aware of. So presence of hypomagnesemia, it actually reduce the efficacy of vitamin D significantly. This is also true for most of the hormone. Even those who are dealing with this are not aware of. For example, the insulin, thyroid hormones and specifically the parathyroid hormone actions are markedly reduced in the presence of hypomagnesemia. Low vitamin magnesium level in the blood will prevent the release of these hormones and thereby its beneficial effects. Secondly, the effectiveness of the vitamin D and the receptor interaction where all the gene activation occurs following that through the second messenger systems. If you look at the immune system in particularly related to the COVID-19 can be enhanced with additional micronutrient intakes and sufficiency.

0:25:43.8 SW: So, this is in addition to vitamin D, we are talking about the vitamin K2 and the small amount of vitamin A and C. But more importantly magnesium, zinc, selenium, omega-3 fatty acid, as well as quercetin and resorcinol and similar micronutrients. So in the presence of adequacy of vitamin, and all these vitamin and micronutrients, one would expect to have the best outcome from COVID-19.

Maintenance dose 50,000 IU weekly

0:26:17.2 SW: So this is a slide, just to show how long it will take to develop, to generate the serum level, as you saw in the y-axis, against the duration on the x-axis. When you give the doses like 400, 1000, or even the 2000 international units of vitamin D per day, it takes about 12-18 months even to come the plateau of the serum level of vitamin D. This was in part, this is actually in part due do, because most of the stuff we get through the diet and supplementation will go to the storage and in the fatty and also don't forget in the muscle tissue where vitamin D are stored quite a lot. Before the vitamin D elevates in the blood, it has to saturated these first vitamin D stores, that's why it take this long to replenish serum level. This is also true even if you take the 4000 international units per day, it takes about 14 to 16 months to achieve a plateau of getting closer to 40 nanograms per mL, it's a good dose, but during which time, the person may not be protected as one would expect.

Loading doses needed first

0:27:42.5 SW: So way to avoid that is actually to, anybody with the vitamin D deficiency in particular, and also it can be done same with the vitamin D insufficiency. Administration is what I call, is upfront loading dose of vitamin D. It could be anything from 100,000 to 600,000 to rapidly boost their vitamin D serum level because it can saturate these vitamin D stores in the body very quickly, and thereby the levels will go up rapidly and that can be maintained with the maintenance dose of something like 4000 international units per day to maintain between 30 and 60 nanograms per mL, so one could also administer the weekly doses of, in this case, either 5000 units daily or 50,000 units once a week. One, you can actually achieve the maintenance dose or the maintenance level of desired level of vitamin D in the blood in nanograms per mL within, relatively rapidly.

0:28:51.8 SW: Here's an example what happen when your loading dose higher level, higher dose of vitamin D like in this case, 200,000 as a single dose which we commonly had been using in outpatient practices for last 20 plus years in a routinely manner. Because when you do that to a level, the patient level will goes up within two days, maximum four days and immune and other system will can benefited by from day three onwards. So you get the very rapid action and benefits from this micro-nutrient converted into the hormone. However, also note that if you don't give us daily supplementation, this level is going to go down because the half-life is only about three weeks, so by the times, the 30 to 45 days, the level is going to come back towards what it was before. So this decay of vitamin D, depending on the dose, if you give a higher dose like 600,000, is going to last about 20 weeks plus. So if you give the 100,000 it'll last about four weeks. So depending on the situation I will come back to that again, you need to identify the right doses to be administered.

0:30:09.2 SW: So achieving and maintain the optimal serum 25-hydroxy concentration, and most of us believe is between 30 and 60 nanograms per mL, will prevent multiple diseases and disorders at least some 40 plus different ailments. The goal for those who are with the comorbid condition, particularly during this COVID-19 era, is to maintain this 25-hydroxy vitamin D level between 40 and 60 nanograms per mL. This has a particular biological reason as this comorbidic condition, most of them are going to need a higher baseline level of vitamin D to overcome COVID-19 associated complication. So it's much safer for elderly, and this is condition which I mentioned at the beginning, for them to have a higher level of serum vitamin D in the range of 40 and 60 nanograms per mL.

0:31:12.8 SW: So there's another smaller study, but it's proved the point that when somebody is having the vitamin D level 30 nanograms per mL and above, the COVID-19 cases per million or the death rate become closer to zero. So virtually 98% of the people are dying from COVID-19 has hypovitaminosis D and this range is actually nanomoles per litre, so to convert these to nanograms, you need to divide this number by 2.5 or here the 75 nanomoles per liter is equivalent to 30 nanograms per mL. The important thing to remember is if the levels are lower, your risk of dying from COVID-19 is high. So this is a study published early this week, it showed that five times reduction of the intensive care unit admissions, those were taking supplements. So, 5% of the people were taking some supplements was a 25 percent of that particular group were not taking supplements.

0:32:22.5 SW: So the huge difference. Similarly, their length of hospital stay was reduced by four days, this is almost like a 40% reduction of length of stay, which is a huge thing on hospital cost and complication associated with the hospital stay. So what are the additional recent data on COVID 19 and vitamin D? This is a slide created from India, although actually many months ago, and similar data is available, but I've deliberately used this one to, which is very clear, the two points I want to mention using this slide is to see that the people above 60 years had the largest number of deaths and in fact, the 63% of people who died in this group of 4281, they were above 60. The vast majority of the people got infected, almost like 80% of them were under the age of 60, but as I know, the death rates are much lower, especially in the younger, death rates, we're talking about 0.1% or less death rate, because they don't have the multiple comorbid conditions and their immune systems are reasonably good.

0:33:46.5 SW: Second point is that there's a male to female ratio varies from 1.7 to 3 times, males are more susceptible to develop complication and dying from it through COVID. There are multiple reasons, biological and physiological, to explain that, which I don't have time today to... It's a different topic, but there is a biological explanation why males are dying faster than females. This slide summarize the effect of the latitude of where they live, whether northernmost or southernmost part of the country of birth and the mortality from COVID 19. Here, you are looking at the Y-axis is the mortality per million population, whereas the degree of the latitude of where people live. So as you see the density living away from the equator, the two ends, the death rates are much higher, you are talking about exponential increase of complication and deaths. So what's a common factor? It is exposure to sunlight. Those who are around the equator get continuously exposed to sunshine more than 300-340 days a year. Therefore, they have some degree of Vitamin D levels in their blood and they are partially protected from developing complications and deaths. And Sri Lanka and other Southeast Asian country located here, the only exception is India. I mention that again, because the India, death and complications are due to multiple different reasons.

Big US increase after Memorial Day – low distancing and few masks

0:35:31.7 SW: So let's get example of effect of mass gathering of people without taking proper precaution, particularly not wearing face masks. Here is the data published from US on June 25th, this is a specific holiday, it's a big holiday in US called Memorial Day, where you can see the three days of festivity and millions of people came to street and enjoyed and without mask and no social distancing, and two weeks later, you can see that almost doubling of the new cases of COVID-19 reaches closer to 48,000 per day. You can see the effects of lack of social distancing and not wearing mask, the basic public health principle of what happened. So to highlight this, I put this slide for you to look at the three pillars of basic public health measures everyone should adhere to. First and most important thing is using the proper effective face mask, because more than 80% of the time COVID is actually transmitted to another person through inhalation, not by any other means. So the micro droplets is the predominant cause of inflammation, not the macro droplet, as some claim. And these micro droplets can indeed can float in the air because they are smaller size and density up to about 20 meters. So in a room, somebody with a COVID-19 sneezing from the bottom at the behind of the last row, the people in the entire room can get exposed and get infections, especially if that person has a very high concentration of virus, as what you call it, a super spreaders.

0:37:27.6 SW: So keeping the social distance of 2 metres will not help in that circumstance, in the presence of a super spreader in that community. Secondly, about... Almost 5% to under 10% of the infections are due to contamination of the fingers through the large droplets deposited on smooth surfaces, like stainless steel or table tops or glass. When you touch, your fingers get contaminated and if you touch any mucous membranes like eyes, nose, mouth, etcetera, it can transmit directly to yourself, what you call the self transmission. Here is the effect of lack of social distancing which is obvious.

Increased risk with Dark Skins

0:38:16.3 SW: So now let's look at the relationship between serum 25 hydroxy vitamin D concentration and death rates on COVID. I'm going to show a series of slides to illustrate this important point. Now we are looking at is a percentage death rate, or survival, and the vitamin D concentration in the blood in nanograms/mL. As you see with the death rate markedly decreases when the people having the higher serum concentration of vitamin D, around the 29-30 nanograms/mL of vitamin D in the blood, deaths rates dramatically drop virtually near zero. In this particular study, there's no difference in the age group what we are looking at, so this is an age-independent factor, serum 25 hydroxyvitamin D effects on reduction of death dramatically.

0:39:16.1 SW: So, there's another aspect is a lot of people are worried about is the skin color. The darker the skin color, the lesser the amount of vitamin D can be produced in the skin. So darker-skinned people like Black, non-Hispanics, Hispanics, and Asians like us, living in the temperate countries, like in northern part of the UK, USA, or Mongolia, or Northern China, there's a very high risk of developing COVID-19 and getting complications and death from it.

0:39:50.4 SW: So, this is true whether you're having the serum concentration of 20. You can see that the doubling of death rate of people with darker skin color, similarly with, even at the vitamin D concentration a higher level, you still see the difference between the two ethnic groups. So the serum positivity indicates that Blacks and Hispanics have a higher COVID-19 rate than whites. So one could argue that if Blacks, Hispanics, and people with the brown skin color, if you can increase their serum 24-hydroxy concentration about 30 nanograms per mL, what I call, population of vitamin D sufficiency, through supplementation or health advice to safe sun exposure, they could reduce a serous positivity that its infectivity and indeed deaths, by about 40%. Very, very cost effective way of handling this, rather than spending millions and millions of their own currency to quarantine centers, curfews, and developing and building intensive care units, all have become redundant and absolute waste of money and resources.

0:41:09.5 SW: This is a study by the... This is not published, but you will see in the website by Dr. David Grimes, he's a senior physician in UK, and shows the point that the effect of the people with a darker skin color, so-called BA Medium, the ethnic minority group has in this. Yes, so he used the group of doctors who died in UK because, it has unique reason for this, because they are... Whether you're white, Black, or brown, the social class is the same. They live in the same environment and their cultural and other habits are generally similar. So you're actually eliminating most of the confounders like socio-economic status, in this particular group of people. As you see, the mean death rate or mean age of the white doctors who died in UK is about 90; many of them are retired. Whereas, the mean death rate of the people with the colored skin, the death rate is about 60. So what you see is about a 30% decrease in age. So these people are dying at 30 years younger than the white counterparts. So, this increased death rates in UK compared to the white doctors who died suggests that importance of having, at least, indirectly, informed us that this is due to vitamin D... Severe vitamin D deficiency in this group of people.

0:42:58.1 SW: So there's another study from UK highlighting the total registered hospital deaths; here, it's on the Y-axis. And the various ethnic groups they have categorized. Again, you can see that the highest death rates are from the people with the Black, Black Caribbean; anyway, the darker the skin color, higher the death rate because these are... These people are not generating enough Vitamin D even for the basic necessities when they move to the northern latitude countries. So they are highly vulnerable to develop respiratory infections, specifically COVID-19, that need the vitamin D adequacy to help maintain the health and prevention of death. This is another study published by Koffman et al. Recently in September, showing that there's a 40% less death rate in infected with... Those who are infected the highest serum concentration. So you can see here, people with higher serum concentration, the infectivity or the PCR positive rates are much, much, much less.

0:44:13.3 SW: So another study to show the severity of the disease as is shown in the X-axis and the probability of getting the disease. For example, the people with the mild COVID or asymptomatic, some of them are carriers, have a 95% or the probability they are having a normal vitamin D levels, whereas those with the severe complication or critically ill in the intensive care units, there's a 95 probability that these people will have a severe vitamin D deficiency. It's a no-brainer, but these people should be treated with the high dose, what I call the loading doses of vitamin D, which can save their lives in a large number of people in the intensive care unit.

0:45:05.0 SW: So similarly, there's another way of looking at it is the... Where the people live, the northern latitude versus a little closer to the Equator and the southern latitude? But this is during December through April therefore, the winter time in the northern and southern latitude is the summer, therefore, it is very similar to those who are living around the equator. You can see that's a big difference between almost doubling of the PCR positive rate in those who are living far away from the equator, therefore, during their winter time almost you can see that level actually double irrespective of the serum 25-hydroxyvitamin D level. So, there are other factors which affecting the complication, acquiring the disease and death from COVID-19. So, I'm gonna show you two slides to summarize the actions or the mechanism of vitamin D in protecting from COVID complication and death. Here, only to show this green area which shows the whole alphabetic soup. It's basically showing the various chemicals generated or suppressed in this case, in the immune system only.

0:46:23.2 SW: You can see that the large number of all these chemical will be altered in the presence of vitamin D deficiency in a very, very negative way. When you have the vitamin D adequacy, this whole thing become positive. With reference to the effect on the respiratory tract, it reduce... Vitamin D reduces the acute respiratory tract infection, inflammatory and oxidative process become significantly less, and the exacerbation of asthma, COPD, even things like multiple sclerosis reduce the incidents and exacerbation, and certainly improve their lung function. Here's what I would like you to remember on benefits of vitamin D in controlling COVID-19. It stimulates all immune cells, especially the innate and adaptive immune system. Innate immune system is the one that become activated immediately following any type of infection, whether it is a parasitic, bacterial or viral infection. Adaptive immunity kick off later, about 7 to 8 days, and that last much longer duration whereas an innate immunity is like a sudden action to prevent infection get hold of your body. So, vitamin D has also a potent anti-inflammatory and anti-oxidative effect and it has multiple antimicrobial properties against viruses and bacteria. And indeed vitamin D prevents cytokine storm, which is due to the massive release of chemicals, series of chemicals called cytokines and thereby prevent a cytokine storm, lung damage and death.

0:48:17.8 SW: In addition, vitamin D also produce... It stimulate the production of neutralizing antibodies, and indeed the compound called ACE, angiotensin-converting enzyme II. It's an enzyme but also a receptor for COVID-19. The production of these two are essential to neutralizing and removal of the COVID-19 and any coronaviruses from the circulation. They can neutralize and destroy it, take it to macrophage cells and those cells will destroy those viruses. So this is a complicated slide, but since this video is going to be available in the YouTube, you can see this leisurely on the effect of the innate immunity in the top half and adaptive immunity on bottom half and how the multi-system functional benefits from vitamin D. This is only one system, which is an immune system stimulation, in a positive way. So, because of that, I'm not going to go through in details, but I will leave that for you to have a look at it. You can pause the YouTube video at this place and you can watch that and go through the details.

0:49:38.3 SW:
So, I'm going to change the topic to another interesting area, why prevalence and death rate reported from tropical countries are so low? The prevalence that was reported in tropical countries is in the range between 5 and 10 deaths per million population. This is compared to over 900 deaths per million in temperate countries, like in the USA, UK, and other European countries. The exception is China, where the death rate is still less than ten per million population. So, there must be some logistical or other reason for having such a low rate of deaths and the infection reported in tropical countries. For most tropical countries, for example in Sith east Asia, are reporting unrealistically low rates of deaths: the question is why?
There are two major reasons; one is these countries carry out less than 3% of the PCR, Polymerase Chain Reaction (PCR) test to diagnose those with the viral antigen than is supposed to. Therefore, when you do very low number of PCR testing, as in Sri Lanka and in other South Asian countries (except in India and Singapore), one can only diagnose few cases with COVID-19 in the community. In fact, these countries never did community PCT or antibody testing until mid-October. Therefore, these countries reported a spuriously low number of PCR positive persons because they're not doing any community testing.

Elderly deaths from COVID-19 not reported before Nov in S.L.

0:51:09.8 SW: All this reported data was based on either hospital or sometimes from quarantine centers. So, lesser is the number of testing carried out lesser is the diagnosis of COVID, therefore the reported death rates are so low. In fact, until end of October, Sri Lanka for example, did not carry out COVID-19 testing in the elderly, most of the elderly dying or people who died in, especially in the peripheral hospital. So none of them were included in those statistic. Fortunately, that has changed that attitude from end of October, and therefore you can see that the rate has gone up quite a bit since then. And the second most important thing for low rates are due to the exposure to sunlight, which is 300 plus days, sunshine is available in tropical countries, and whether people like it or not, they get some exposure to sunlight, thereby developing some vitamin D, which enough to just manage to prevent complication and deaths.

0:52:19.0 SW: So to show this important point, I'm going to show just a couple of slides. Here's a Northern Europe summarized data from 2010 to 2018. What you're looking at is the about 95%-98% of all respiratory viral infection occurring through December to mid-April each year. So this is exactly the peak of winter, when there is a less sunshine, and therefore less amount of vitamin D, and the best time for viruses to thrive and multiply more. This slide shows that second point. The presence of low temperature, low UVB index, and drier weather condition in light blue color, viruses are thriving. Their viability increases, their infectivity increases and the viral loads dramatically goes up among the three condition.

0:53:22.4 SW: Again, these three condition do not exist in tropical countries and therefore are not infective. So the misleading statistics provided to the WHO from these countries, with the exception of India, it's mostly due to the absence of testing, community testing, PCR testing and antibody testing, or even rapid antigen testing in these countries. So based on the large number of the community studies done, it has been estimated that between 10 and 40 COVID-infected person are present in the community, 95% plus of them are asymptomatic. So they are not being diagnosed and not included in the COVID statistics in tropical countries. For example, when Sri Lanka is doing 500 now, but 10,000 PCR a day, United States is doing between 500,000 to 800,000 COVID PCR testing each day. So you can see when you convert to the million population basis, Sri Lanka is still carrying out only about 8%-10% of the test that need to be done even with the 10,000 tests as currently done.

0:54:46.2 SW: So, to assess the true number of people who are PCR positive, that may have been infected, reported prevalence must be multiplied by an average factor of 20. So you know the number of people reported as PCR in your country, and you can multiply by 20 to get a estimated number of people who are infected, mostly asymptomatic, in the community. Some of them can spread the disease, some do not. So combination of these two key factors are the reason for the statistics of providing the misleading low numbers of COVID infection and deaths from these countries. Some people have asked the question that, does medical care is responsible for the prevalence of COVID-19? Answer is, absolutely no. Let me give you example for Southeast Asian countries, and again, I'm not going to read the slide. You can read this leisurely.

0:55:52.8 SW: So there's up to about 64 difference in the number of hospitalize beds and other healthcare parameters to show good and bad healthcare system in the South Asian countries. So when you compare Bangladesh and Singapore, all this will applicable... Sri Lanka, India, Malaysia comes in between. The point is, except for India, which has as I said, it has a different reason for high death rates, all other countries, the Southeast Asian countries have reported very, very low PCR positivity and death rates, irrespective of the huge difference on the healthcare availability and delivery from good to bad. So healthcare really has nothing to do with the infectivity... No, generally the death rate, except for the few people, less than 3% of the people who get admitted to the intensive care units.

0:56:54.1 SW: These vast majority of the people will get better, whether they are treated, not treated or do whatever the other people want to do, the people are going to get better on their own. So this slide, again, I'm going to leave it for you to read leisurely in the YouTube. You can see my post there and have a look at it. It summarizes all the factors in the tropical countries where you live, and the erroneously misleading COVID-19 statistics reported to WHO. But these are the factors affecting to that low numbers, which is not realistic. But that's what they had developed and found and they were reporting to the WHO. So let's move on to the next area, to summarizing the reason for very low prevalence of and the death rate in tropical countries, again, for two reasons, although there are multiple other reason in the previous slides you can go through.

0:57:53.3 SW: The low prevalence of COVID-19 and low deaths reported are simply due to either logistical or natural reason. Logistical is you don't do number of PCR tests, therefore you don't diagnose. Naturally is the availability of sunshine and reasonable immune systems. So low number of PCR testing and reasonable population vitamin D levels are the one responsible for low reported numbers, nothing whatsoever to do with the curfews, lockdowns or any form of healthcare intervention or any governmental actions.

0:58:35.6 SW: The right way to present the basic statistics related to public health, in this case, PCR tests and the death rate from COVID is presented in this slide. So you need to converted that into a rate. Presenting the raw numbers as happening in the TV and radio on the daily basis is pathetic and absolutely wrong and misleading. So the number of PCR tests, positive tests should be divided by the total number of PCR tests carried out, whether it's in a day, a period, like a week. That's okay. And then you multiply it by 100 to generate the rate. So that basically you standardizing the number of tests versus the PCR positivity, so that one can compare within your own country or compare with the other countries. Similarly, the death rates from COVID-19 should be reported. COVID-19 related deaths divided by the total number of COVID infected people in the country, entire total number, multiplied by the hundred. So this is the right way to do that, should never, ever present the raw PCR positive patients, and this and that, which is totally misleading, and unfortunately continuing, annoyingly continuing every day.

1:00:00.4 SW: So the curfew was, unfortunately, this October curfew was based on the increasing number of positive PCR tests and they forgot to look at the rate of change, which was no different from May, June, July to October, so they miscalculated. Those who made the decision, miscalculated the true incidence of COVID-19 and for the yet another totally unnecessary curfew causing further trouble for people and the economy. So if you do the calculations, basic calculation, the rate change from April, May, June was 2%, to current October-November is 3%. So there's no statistically different or exponential growth of virus or spread of the virus. This 1% change was fully accounted by the increased number of PCR. In fact, it increased by 24 from 500 to 10,000 and testing in the community for the first time in high risk population. In fact, I was surprised that even only 3%, I was expecting to go up even higher, nevertheless, the point is there's no significant difference of the positivity rate from early part of this year to now, October-November.

1:01:26.7 SW: So this error of judgement of basic statistics, led to the enforcement of yet another unnecessary curfew. So whether there's incidents prevalence, severity, that is, ICU bed occupancy or deaths, the number must be presented as a rate, percentage or at least as a PCR positive person per million population basis, so that it is a meaningful and comparable and you can look at the changing within your own country. The raw data must be standardized as a rate as mentioned in the previous slide, and presented to the public and to the WHO. So, I am going to present only two slides on medication and vaccines, because that's not what my interests are, neither the public interests should be on the disease prevention and the time and effort should be diverted to the prevention of the disease rather than using expensive medication and vaccines, which is worthless effort.

hydroxychloroquine

1:02:41.5 SW: So except for the hydroxychloroquine, there are no other cost-effective pharmaceutical agent available to treat COVID-19. Again hydroxychloroquine is a different story, it was shown that is highly effective if you use the standard dose in early part of the disease, not the person who is admitted to ICU, it does not work, and it has a tremendous effect of disease prevention, prophylacticaly or early stages of COVID. Yet due to conflict of interest from big Pharma and funders of Pharma, it has been discredited for no apparent reasons. Some people are claiming it has a very high adverse effect, which is absolutely not true. Tropical countries like Sri Lanka, India, had been using hydroxychloroquine for five or six decades case as to control malaria, and even in the west, hydroxychloroquine was freely used for immunological disorders for the past 40 years. So the creation of stories that hydroxychloroquine causes heart blocks and all these things, is really to prevent people using the cheaper agents like hydroxychloroquine and those people who are making these claims want to them to sell the expensive antiviral drugs, which I'm not even going to mention in this presentation.

1:04:11.2 SW: So this is true, irrespective of the type of medical system in your country, whether it's western, eastern, Yunani, Ayurvedic or any hybrid system, none of the system can eradicate the virus, once a virus enter into your system. Similarly, the people who get infected with the virus has absolutely no way, he or she can get rid of the virus by doing all gimmicks like steaming, salt water, increasing body temperature or whatever, it's not going to be effective. So don't waste your time and money and also put your life in danger by trying to change your body temperature and all this nonsense, which has nothing to do with COVID control. So only thing what you can do is to stay in the sunshine or take some micro nutrients supplements to boost your immune system, that is the only way that your body can fight against the COVID-19 and you do not develop any complication or death. In fact, in my opinion, the use of high dose of vitamin D, which cost less than $5 to $8 per person, is likely to be much more effective than any COVID-19 vaccine.

1:05:36.3 SW: And indeed it has got zero probability of complication compared to vaccine, which has a significant high morbidity with a coronaviral vaccines. So if you look at the big picture now, if you look at the postulated defence against COVID-19, there are vaccines coming up, antiviral therapies, they are very expensive, and nothing in between, practically one you could use to overcome the problem, except boosting the immune system with sunshine and vitamin D which can prevent all these complication happening, particularly the cytokines storm, and get out of the ICCUs with a full recovery. In the absence of adequate amount of vitamin D, the death rates as I showed in previous slide, is going to be skyrocketing.

1:06:31.2 SW: So the single slide on vaccines in my comments, despite all these hypes and false propaganda by various companies and people who're funding the vaccine, and indeed some governments, desperately trying to bending backwards to purchase or take a donations of these vaccine, they're absolutely wrong. Firstly, it's expensive and unaffordable for the majority of the population, so to whom are these companies offering vaccine? The rich and the elite and the politician? Or the common people like you and I? Who cannot afford to have these vaccines. So they're not protecting the world with so called COVID-19 vaccine. There are multiple safety issues and we've already shown that the people are developing serious adverse effects and in some case even death following the vaccine, it's a single dose.

1:07:34.7 SW: Unfortunately, most of these vaccine needs at least two doses, with weeks apart, so that adds to the expenses plus the more side effects. It's effectiveness, what you call, adaptive immunity, may not even last beyond few months. This we are not sure, but based on some people who had COVID-19 infection earlier this year and getting re-infected suggest that this adaptive immunity may have some issues. And that's why there're some people, albeit smaller numbers are getting re-infected. Look, if this is the case, we're going to need repeated doses in years to come. This again causes expenses and serious adverse effects and possibly death. And one of the most important thing actually many of these new COVID-19 vaccines need to be frozen at minus 70, and that kind of thing, during the transportation and storage.

1:08:37.8 SW: And the vast majority of the countries in the world do not have such capacity. Again, my question is, if that's the case to whom these companies like Pfizer and others, developing this vaccine for? So what I call it's a fool's paradise for rushing to jump by administrations and countries to any corona viral vaccine, particularly the COVID-19 vaccine, whether it's out with a free donation or purchases, they need to think three times before making that decision, which may not be for the benefit of the country. And especially as some believe that the corona viral epidemic, actually pandemic is already getting over by early next year, then why they're subjecting people to harmful vaccines, which effects can last for... Effects mean the negative effects could last forever in these people.

1:09:40.3 SW: So dangers associated to COVID-19 vaccines are too high to subject a population to it, compared to potential benefits, not knowing its adverse effects, benefits and indeed associated costs. So I'm going to show you these two slides on the currently registered ongoing vitamin D COVID-19 randomized controlled clinical trial. These two slides are from the VitaminDWiki run ran by my friend Henry Lahore. This is the very early studies, I think in the either May or June, that time had a 18 larger studies. You can see that the number of patient varies from 60 to 3000 and many of them are still underway. In fact, the COVID prevention study in Sri Lanka, we're planning to use 400,000 IU single dose in quarantine centers in 2,000 subjects which were completely sponsored: so, no cost to the government. Unfortunately, the approval was not yet given to that study.
.

1:10:56.8 SW: So by the end of August, September, there was some 34 registered studies in the nih.gov website. Right now it's something like an either 49 or 50 studies have been registered. These are very large studies associated with the 3000 sometime 27,000, and large number of patients, have been recruited for these studies and results of which will be available, starting to be available from December onwards, early next year. So let's look at the, how does vitamin D adequacy protects human from Coronaviruses, very briefly. And we'll also touch on few mechanisms and how Calcitriol block the Coronavirus entry into the human system.

1:11:48.6 SW: So, adequate Vitamin D levels, I showed you multiple times in the previous studies have been associated... Shown to be associated with a reduced incidence, and more importantly, the complication and deaths from multiple corona viral diseases including SARS and MERS. And in addition, the Vitamin D sufficiently will reduce the severity and the chance of getting infected with the herpes, Epstein-Barr virus, hepatitis, ebola, HIV, dengue, measles and mumps. So all these viral disorders will respond to having adequate Vitamin D levels. So overall there are multiple benefits.

1:12:36.7 SW: So this cartoon summarized the cause of death from coronaviral-19 as we knew three, four months ago. So coronaviruses, in particular COVID-19, enter through the so-called ACE2 receptors, angiotensin-converting enzyme 2 receptors, predominantly through lungs, but also through mucous membranes and the gastrointestinal tract. It causes acute lung injury in the absence of having good immune system. It can also stimulate the renin-angiotensin hormonal system, which further exacerbate the lung injury and the cytokine storm. So this causes the primary hypertension, edema and microvascular disease, especially a small vessel disease with the micro-thrombosis and embolism into lungs, which added to acute respiratory distress syndrome, and deaths due to this and as well as pneumonia.

1:13:43.3 SW: So this is a busy slide. I'm gonna spend a couple of minutes to explain it. It's showing the vitamin D adequacy. This is 1,25 dihydroxy D. It's a Calcitriol. When you have the adequate level, it suppress renin thereby suppressing the angiotensin II, which is the most potent vasodilator and also one of the key factors of pushing the cytokine storm. So this access is suppressed with vitamin D. In addition, vitamin D suppress the coronavirus-specific pathways also. Coronavirus reduce the ACE2 that's blocked by vitamin D. Similarly, that's direct action of calcitriol prevention of dissemination of coronavirus within human body.

1:14:29.9 SW: So, furthermore, so when you suppress a cytokine storm through vitamin D adequacy, it stops or prevent virtually totally acute respiratory distress syndrome, so-called ARDS, pulmonary edema, hypertension, complication, and death. On the sideline that, we also see that there are a lot of, millions of people in the world are taking angiotensin-converting enzyme inhibitor and angiotensin receptor blockers for hypertension control and protection of the kidneys. So as you see that these two agents also reduce the level of angiotensin II and thereby the production of cytokine. Therefore, it may have a peripheral role and benefiting people who are already on ACE inhibitors and ARBs and they should not stop taking those drugs because that can be beneficial.

1:15:29.5 SW: So let me put a summary on the conceptual diagram of coronavirus. So seen from the virus entry, vitamin D can prevent entry and activation of these receptors so the blockage of entry of the virus, as well as reducing the production of angiotensin II from this hormonal system, ACE inhibitors and ARB blockers, I already mentioned in the previous slide, and the new medication could fit into the latter part with the people who are dealing with complications and absolutely no reason whatsoever to give these expensive medication with the serious adverse effect in the early part of their disease with the people without complication. I'm also referring to dexamethasone, which can actually aggravate the situation if you give it to the wrong people; the 80, 90% of the people who does not require any of these medication at this time.

1:16:34.2 SW: Let me summarize now the COVID-19 vitamin D story. Those with the 24-hydroxy vitamin D concentration above 40 nanograms per mL rarely contract COVID-19. Even if they contract, they'll be. mostly asymptomatic. Most industries will continue to get affected from the COVID-19 epidemic which could become... Pandemic which would become a epidemic next year. This includes the airline industry, oil corporations, automobiles, banking, tourism, hotel industry, and all supply chains. That's most of the production have been affected. Oh, these are get to more worse affected in the countries which inappropriately use curfews and stay to a large area of lockdown. Lockdown should be used in a very small for geographic region to prevent the disease spread, and never ever to use larger scale curfews or even lockdown in the districts, or state-wide, or the country-wide. It's actually significantly counterproductive in affecting negatively the people and indeed for downfall of the economy.

1:18:03.5 SW: So in addition to the public health guidelines, following those, the recommendation for the high-risk groups are as follows. So let me explain what are the high, three high-risk groups I'm talking about. Firstly, the frontline workers, like healthcare workers, contractors like army, law enforcement, police, etcetera. And anyone dealing with COVID-19 patients, including the social services and public health inspectors, etcetera. Second group is a public who are at greatest risk of COVID-19. They are the elderly, those with the diabetes, obesity, any chronic diseases, especially the cardiovascular, pulmonary and kidney. And then high, those who are with the high social contacts.

1:18:54.9 SW: And the last category is for those who, with the recently identified as PCR positive. Some of them could be falsely positive, some of them may be falsely negative, based on the quality of the PCR testing, and indeed the COVID-19 zero positive patients, people. So these three categories, we strongly recommend you to taking action to provide them with the high dose, single dose upfront Vitamin D in the range from 100,000 to 400,000 International Unit, as a stat dose, one time dose, which can be repeated after 10 to 14 weeks. So this week, the goal is to rapidly increase the serum 24 -dihydroxy Vitamin D concentration that will, within a day or two, start boosting the immune system so that the people themselves have developed the strength of fighting COVID-19 and come out of it.

1:20:01.3 SW: That's the best and the only way people can get over COVID-19. So giving this high-dose upfront loading with Vitamin D should be followed by taking either 4000 or 5000 International Units of Vitamin D, depending on the availability of the capsules, or one could try also 50,000 International Unit capsules. In India, it's 60,000 per week. Or repeat the above high-dose of Vitamin D on a eight to 16 to 18 weeks interval as appropriate. No adverse effects have been reported with this above-mentioned high-dose Vitamin D regimen supplementation to date, especially with reference to COVID-19 therapy.

Body Armor

1:20:52.1 SW: So this is the slide created by one of our colleagues, Henry Lahore, who owns VitaminDWiki. He created this as a body armor concept for military, for example one could give a vitamin D 100,000 unit once a month, or 400,000 unit every once in four months, to keep them healthy and preventing getting infected with COVID. And at the same time, you have a contingency group here, as is showed here, reserves companies with the boost indoors intermittently so that they can exchange with, for example, the army or police, law enforcement agency on a strategic basis to have a healthy force available to do whatever the country needs. So this is the strategy called use the vitamin D as a body armor to protect COVID-19, from COVID-19. So it has an interesting additional reading of the dosing regiments available. One could go to this website, newmedie.com. There's a good article from my colleague about the doses Vitamin D protect us from COVID-19. What's the required dose? So it varies from country to country from ethnic groups, and I strongly urge you to go through some of these websites and publications.

1:22:22.5 SW: , In summary, I mentioned that taking 4,000 International Units of Vitamin D, in the longer term will maintain a healthy level of Serum 25-hydroxy D in 95% of people. However, it usually takes many months to achieve this and therefore, not adequate for any acute situations, including COVID-19. it's necessary and wise to administer loading doses between 100,000 and 600,000 in some countries to rapidly boost the immune system. These are life-saving measures and not gimmicks as antiviral drugs and vaccines. So this large doses should be followed up with the daily maintenance dose between 200 and 5000... 2000 and 5000. You need the preferably standard dose of about 4000 units of oral vitamin D on a daily basis, preferably with sun exposure. These strategies will save lives, save the economy, and is highly, highly cost-effective. So Vitamin D deficiency induces disorders are common, multiple disorders, and they are preventable with a very, very low cost anyways. With reference to COVID-19, the adequate Vitamin D levels prevent COVID-19, related complications and indeed, deaths. Then why not?

1:24:03.5 S1: Thank you. We'll have time for questions, and the moderator, I think, Dr. Mahawithanage is going to ask questions, and we'll take as much as questions possible during the time limitation. Thank you for participation, and we'd like to welcome you back in another Zoom session in the future with a slightly different topic as things are moving ahead and things are... And the second wave is halfway through, and the vaccines are coming in the market, and things can change. So we'll have us another meeting, Zoom meeting on the different topics in future. Please join, join us then. Have a great day. So this slide summarized some of our activities for what we worked through the charitable foundation, called Wimalawansa Foundation. And anyone who is interested in joining us to help people, the needy and the poor, you're welcome to join us through any of these means. Thank you again.

Questions

1:25:16.8 SM: Thank you very much, Professor Sunil Wimalawansa for that excellent presentation. With that, let us open the floor for discussions and comments. I have got a list of questions, so I will be posting them to Professor Sunil Wimalawansa as they come. Professor Sunil Wimalawansa, one of the questions that I have received through the chatbox is that you talk about vitamin D, and we are living in a tropical country, so there is ample amount of... We are exposed to sunshine, so do we really need to worry about vitamin D content in our bodies?

1:26:01.9 SW: First of all I think it's an excellent question. I'll answer that on a three different parts I guess. So there's no part of the world where one would be immune from getting vitamin D deficiency. So let me explain that. In fact the vitamin D deficiency's highest when you move away from the equator like the northern and the southern most part of the world. Having said that, around the equator also the vitamin D deficiencies are pretty high, in some countries, it's as high as 70% of the population. So let me explain why is that. Because although that we have the sunshine, weather conditions are very harsh around the equator, like middle-eastern countries, therefore, people do not get exposed to sunlight during their summer period. In fact it is the opposite of UK, and the northern part. During summertime they had the vitamin D deficiency because they just avoid sun totally, and during the winter time the sun is mild, and therefore they get out and vitamin D deficiency improves.

1:27:10.4 SW: So coming back to tropical countries, like in south-east Asian countries, the issues there is actually, for traditionally, for cultural and cosmetics reasons, people avoid getting exposed to sun, even though sunshine is not that harsh. So in average, whether they, even they avoid the sunshine, they get some exposure to sunlight during the peak time. Therefore, very very difficult to find people with a severe vitamin D deficiency in tropical country. In fact, that's one of the key reasons why people are not getting severe complications and death from COVID-19, because people have a certain degree of vitamin D, whether they like it or not, thank you.

1:27:57.6 SM: That leads to my next question, sir. If we are to get the maximum out of the... From the sunlight, is there a particular time that we should get ourself exposed?

1:28:12.5 SW: The answer to your question is, absolutely yes. The reason is that the sun rays need to be in an acute angle to penetrate your skin, or my skin, so that's... Having said that, that's between 10:30 in the morning and 1:30 PM in the afternoon. During that two-hour period, two and a half hour period, the sun rays are... Is able to penetrate the skin to the dermis, so that it can react to convert the 7-dihydroxy cholesterol to create vitamin D, so that's the scientific reason behind. So timing is very important. Two things, firstly, before 9:00 AM and after 3:30 PM, very very little vitamin D you can produce through the skin. Exactly the same thing applies to during the winter period in northern and southern latitude countries. They produce virtually zero vitamin D, even though they can spend three hours in sunlight, 'cause of same principle.

1:29:14.7 SM: So Professor Wimalawansa, a country like ours is concerned, what is the best duration that one should get himself or herself into the... Get exposed to sunlight?

1:29:26.6 S4: That also give me opportunity to answer another question where there's... People have... A lot of people ask me whether the timing which I mentioned from 10:30 to 1:30, whether it's different for different countries, absolutely not. Whether you live in UK, USA, Sri Lanka or Australia, the timing is... The timing for the country where the sun is on... At the peak. I'll give you another clue, very easy thing to remember. When you go out, at say, 11:30 in the morning, if... Your shadow should be less than your height. So that's a good clue and very easy to find. If your shadow is taller than you, then the sunlight will not be able to penetrate your skin.

1:30:09.4 SW: So coming back to your question, the places like, Sri Lanka and India for example, the duration of stay in the sunshine depending on the melanin content, in other words, the darkness of your skin. The darker your skin it acts as a barrier to ultraviolet ray penetration to the dermis, to produce vitamin D. So the darker your skin, the duration you need to stay in the sunshine increases. I'll give you an example so that you understand it well. So that... In Sri Lanka for example, the white person and a dark person stay in the sunshine for say one hour. The whiter person will produce six times more vitamin D than the darker person. So that means that the brown and the darker skin person need to stay a minimum of 30 minutes, preferably more than that on a daily basis, under the sun to have the maximum benefit.

dark skin ==> 800-2500 IU in 30 minutes

1:31:13.4 SM: With that, there's another question that just appeared, sir. So that means on average, if you consider an average person in a country like Sri Lanka or India, exposure to sunlight 30 minutes a day would be sufficient to produce the recommended amount of vitamin D?

1:31:33.8 SW: Okay again, it's an excellent question there. I generally say that the 30 minutes is reasonable for Sri Lankans because Sri Lankans are, their skins are not dark as West Indies and other African countries. But then, if you're talking about the one and a half hours or two hours in sunshine, it's very difficult. The Sri Lankans average skin melanin content is what I call it the Fitzpatrick level three or so, really it's like right in the middle. So 30 minutes will, on average, can generate anything from 800 to 2500 international units of vitamin D, provided that if you have a one-third of the body's skin surface area is exposed to sunlight.

1:32:25.4 SM: So the next question that I want to ask you before we move into the COVID and vitamin D is that apart from the exposure to sunlight, what are the other potential sources of vitamin D?

1:32:43.1 SW: Alright. So let me answer your question. I need to add something after that. So the problem is you can have very balanced diet, nutritious and still become vitamin D deficient. It's surprising for some people, I've been getting the best diet in the world, I am still vitamin D deficient. The reason is a diet provide us with very, very little vitamin D. In fact that most of the vegetables and cereals and things give no vitamin D. Only vegetable that can provide the reasonable amount is sun-exposed mushroom.

1:33:18.0 SW: It's critically important that they're sunned mushrooms. Before you cook, you need to put upside down and put in the sunshine for a couple hours. Then you can increase the vitamin D content by about four to five times. Still, you're talking about 800 to 1000 units per 100 grams of mushroom, not much. The other source of vitamin D is any fatty fish like mackerel, sardine, salmon, tuna. So those fatty fish also have the natural D3 they produce and store in their fat mostly. So other than that, there is virtually no other food can actually provide the vitamin D sufficiency except in a given country, the milk, and cereal, and breakfast cereal and things are also... Are fortified with vitamin D. That's a good source of regular intake of vitamin D.

D3 vs D2

1:34:13.2 SM: Professor Wimalawansa, you talk about two types of vitamin D's in your presentation, vitamin D2 and D3, do you see a vast difference in these two or both are equal?

1:34:25.9 SW: Until about 15 to 20 years ago, we believed that D2 is equivalent to D3. Now with the latest data, especially the proper dinalty data and the bioavailability, we know that that's not true. In fact as I showed in the early part of the lecture, I produced a structure of the D2 and D3. Please go back and review, they are slightly different. So the major differences between the two are D2 half life in the circulation and tissues is lower, almost 50% lower, and therefore it does not remaining in the system, body system for that long duration. Secondly D2 is come from the plant sources exclusively. D3 is from the fish and also the natural source of is D3. Receptor point of view biochemically in the potency to, calcitriol to vitamin D receptor, affinity is the same though. However, if the chemical is not lasting that long in the blood, so naturally the potency over a period, what you call the a!rea under the curve will be less with vitamin D, D2. So the preferred source for supplementation is the D3.

1:35:47.4 SM: So in other words, what you're referring to is that the D3 is likely to be the most effective form of vitamin D source.

1:36:00.2 SW: Yes, it is a natural hormonal form for human. There's one caveat there, the people, the vegans, they may not like even the vitamin D capsules made of gelatin, for example. So for them, you can have the capsule made up of totally algae and things like that. On D2 they are really, really particular about D2 then they can take D2 but at an almost twice a dose than recommended.

1:36:31.4 SM: Before I move into the other question, which is basically the COVID and vitamin D. I would like to know Professor Wimalawansa your opinion about the current pandemic of COVID and the measures to prevent it, like even the vaccine or even the social distancing. Do you see that even a vaccine alone will help us to control this COVID-19 pandemic?

Mainly asymptomatic transmission in tropics

In lecture for another 90 minutes. So the issue with, multiple issues. It's misleading to say that, adhering to all the standard public health measures is adequate to control vitamin D. It is not. There are two reasons for it. Firstly, the most of the infections are occurring through asymptomatic carriers. So we cannot detect those asymptomatic carriers in the community unless the government or health department is doing the community-based testing. Sri Lanka, for example, did no, zero community testing till mid-October 2020. So they missed out 95% of the people who was infected in the community, and therefore they remained spreading the disease, that's why it became a communities... Multiple Community Clusters. So the second part is actually, even for getting the disease, people with a certain amount of immunity, get a very mild disorder, just like a common cold or flu. So the diagnosis of this group of people who still can spread the disease is difficult unless you do the proper testing.

1:38:25.6 SM: So also in terms of the other remedies like a vaccine, what is your opinion about, will it be able to control the pandemic fully, or do we still need some other measures?

1:38:39.9 SW: Correct. So again, I'm gonna ask the hypothetical question before and then answer your question. Currently, in fact, there are only two agents... Three agents who can be effective in prevention, in treatment of COVID-19. Prevention point of view with vitamin D is the only effective option for prevention of the disease and prevention of the complication. Early stage of the disease and also to a part prevention, hydroxychloroquine at the right doses, the right duration can have a major effect on controlling symptomatology and complication, prevention of complication. Third group of medication that we've been shown to have effect is a dexamethasone, which is a very, very potent glucocorticoid agent. But however, this is only indicated in about 4% or less than 5% of people admitted to the intensive care unit with a respiratory and other difficulties and complication. Only in this group ever, hydrocortisone or dexamethasone should be administered.

1:39:54.4 SW: And if administered properly, it might be able to prevent, what we call it, cytokine storms, and damaging, acute lung injury and death. Whereas if you administer glucocorticoids or dexamethasone for somebody with a milder or moderate disease, you can actually make them much worse and you can actually create complication and death on those patients. So, you need to use some medication very, very carefully on the selected patients to do that. So let me answer the question of why the vaccine? To date, there never had been a good safe and effective vaccine for any corona viral disorders, basically RNA viruses. And experts had been estimating originally that it usually takes about five to seven years to develop such vaccine because you need to have a safety precaution, multiple levels of testing to be done properly. Unfortunately, because of the competition and the greed of pharmaceutical agencies, they have cut short that to six months. You understand that anything cut short that dramatically from seven years or six years to six months, you are going to have problem.

1:41:11.5 SW: In fact, some of the vaccines tested in Brazil, for example, there had been deaths and nobody wanted to talk about it. So, I think that jumping into the vaccine bandwagon is too premature and will have significant negative effects on future generations to come.

Why have govts. not responded ($$)

1:41:35.9 SM: Sir, now you have clearly highlighted in your presentation the existing evidence of effectiveness of vitamin D in the prevention of COVID-19 infections. Now, my question is that if that is the case, why not any government even in any industry has not actually taken up the point and driving this towards coming up with another supplementation regime or something like that?

Hydroxychloroquine

1:42:07.6 SW: Thank you. I mentioned the name of the drug called hydroxychloroquine, which had been used for almost 70 years to control malaria and in recent days have been very successfully used for rheumatoid arthritis, and other immune abnormality related disorders, very successfully. It has a rare adverse effect in the cardiovascular system, cardiac arrhythmia (prolonged QT syndrom) it is very rare. The incidence is about 1 in 8,000 people taking this medication. This prolonged QT syndrome automatically subsides once the drug is stopped. So, it's a very safe drug so as the vitamin D. Issue is actually, both vitamin D and hydroxychloroquine are exceptionally cheap, under five dollars for a full course of treatment of these medications. This is in comparison to antiviral like what is available now, we are talking about $10,000 to $50,000 dollars' worth of expenses. Same with the antiviral vaccines are going to cost quite a few because they need to be given repeatedly.

1:43:22.8 SW: So, as you see that there is a conflict of interests not only from the industry, but mostly from the investors and the politicians basically to generate more funding and money using the expensive modes of treatment course. In fact, they are not even trialed properly and approved for safety, rather than using the already available, very tested things like vitamin D and hydroxychloroquine. They are very safe and exceptionally cheap to use.

1:43:54.5 SM: So in that context, Professor Wimalawansa, what is the most safest therapeutic dose of vitamin D in prevention of infectious diseases?

1:44:05.8 SW: So, there's nothing called the dose for COVID-19, that's because everybody is different with a starting level. The issue is people who come into the Intensive Care Unit and dying of COVID, virtually 99% of them had a severe vitamin D deficiency, I'm talking about the levels less 10 nanograms per mL, they're exceptionally low level of vitamin D. So they don't have the innate immune system to fight against the invading pathogens, including the viruses like COVID-19. So we need to break that viscous cycle by increasing, not only the individual vitamin D status, but also population Vitamin D status. That must be the strategy to prevent COVID-19 for any given country.

1:44:55.2 SW: We had that opportunity in March, I proposed but no one was interested in Sri Lanka to do that. If you do that and increase population Vitamin D level above 30 nanograms per mL, entire population, actually, age from 10 and above, there's no reason whatsoever to have lockdowns, curfew, or any economic restriction. We could then manage the country as nothing has happened, 'cause no one is going to get sick and no one is going to need hospital administration. There's no need to prepare 5000, 6000 beds on quarantine center, absolutely no need to expand intensive care unit. Yet administrators and politicians doesn't seem to understand or doesn't want to understand the safe and already available mode of prevention of COVID-19.

1:45:48.9 SM: So, professor Wimalawansa you are basically recommending a mass scale vitamin D supplementation program. So the last question is, now we know that the Vitamin D is not a water soluble vitamin and can cause us toxicity if you take a very high dose, so how do you ensure the safety of such a supplementation program?

1:46:12.1 SW: So, I forgot to answer the second part of the previous question, you asked me if there is an average dose. Average dose to maintain serum level about 30-40 nanograms per mL is about 4000 international Units per person.

1:46:29.7 SM: Per day, sir.

1:46:30.8 SW: 4000 International Units per day orally. And normal, in the absence of COVID-19, the average dosage need for a population is between 1000 and 4000 International Units. The problem is the COVID complication and death occur in people with multiple comorbid conditions, like diabetes, hypertension, kidney failure, those kind of things. So, to control those comorbid condition, you need... Most of them need about 40 nanograms per mL in the blood flow circulation to overcome that. Because of that, we in the academia, we recommend that to keep the vitamin D level above 40 nanograms per mL. In other words, a range between 40-60 nanograms/ML is the most effective way of doing that. Second issue is somebody come on an emergency situation to a hospital or a general practitioner with signs and symptoms of some exposure to Vitamin D, you need to boost their immune system immediately, within a day or two.

4,000 IU has too slow of a response

1:47:41.2 SW: So, giving 4000 Units Vitamin D will not touch. It takes 90 days to actually raise up that level. In those situations, I urge the physicians, and the practicing physician and health care workers to prescribe and give them a high dose vitamin D upfront. What we and the most global physicians are using is a dose of between 100,000 and 400,000 as either, stat dose or given on a daily basis, something like 50,000 Units for the next five days, or something like that. So what we are doing here, actually, giving a high dose upfront, not only to raise our blood level, but also start boosting the immune system. It usually takes about 2-3 days to do that. So that difference is very important to remember. So 4000 is a maintenance dose, whereas you need to boost your system quickly as possible using the high dose upfront loading dose. Sanath, can you summarize the last question?

1:48:41.4 SM: The last question is that, now, if we are to go for a mass scale Vitamin D supplementation program, knowing the fact that Vitamin D is not a water-soluble vitamin, how do we ensure that there will not be toxicity and the other side effects of vitamin D high doses?

1:49:00.7 SW: Actually statement that Vitamin D is essentially not a water soluble, yes and no. So, when you take the oral vitamin D, it's always better to take with a little bit of fatty contain... Something to do with a fat. So it definitely enhance the absorption. Having said that, Vitamin D is also available as a powder in the water soluble form, that can be dissolved in water and given in appropriate amount. So that's why I said, the yes and no on that. So, second part of the... Important part of the question is, to get toxicity from vitamin D, any form, you're going to require getting the blood levels above 150 nanograms per mL. That is about 350 nanomoles per litre, huge level.

1:49:48.4 SW: To achieve such, you need to take millions of units of Vitamin D, not 200,000-300,000 they won't even touch. Because of that, the incidents of vitamin D toxicity is exceptionally rare, and in the community it's something like 1 in 100,000 or less. So you can see how rare it is, vitamin D toxicity. And most of the reported toxicity due to vitamin D is either taken deliberately as poison, or they forgot to read the label and taken a very high doses. For example, in Canada, some time ago, there was a preparation, each drop was a one million unit. So, this was given to children with unknowingly they assumed that it's about 1000 International units, but actual dose of one million. But a dozen of the kids got toxic pretty quickly taking 10 million or even higher doses of vitamin D. So I don't think some people listening to this or Watching this need to be worried about vitamin D toxicity, because the recommended doses will never achieve that kind of a higher blood level of Vitamin D.

1:51:05.1 SM: Thank you very much Professor Sunil Wimalawansa, that ends the time allocated for question and answers session. Before we conclude, I really wanted to thank all the participants for their patience, because today's webinar is a great success, we have nearly 80 participants attending all around the world today. So also, I would like to thank Professor Sunil Wimalawansa joining with us today on behalf of the College Of Biochemistry, Sri Lanka, and we will meet you again in another monthly webinar. Thank you very much.

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