Vitamin D and COVID-19

The news media have been extensively covering the publication of research papers over the summer that suggest that vulnerable people should all be taking vitamin D supplements as a precaution against being infected by COVID. If you have been reading these reports you may be wondering what you should do?

Vitamin D is sometimes referred to as the ‘sunshine’ vitamin as we are all able to make it in our skin when the skin surface is lit by the sunlight. Our bodies cannot make it without sunlight so NHS recommendations are for short periods of direct sunlight on our face and arms every day. We can also get vitamin D from our food, principally oily fish, eggs and red meat.

Evidence shows that many of us (20%) in the UK have quite low levels of vitamin D in our bodies, especially during the darker months (October – March) when we don’t get much sunlight shining on our island. There are also people who don’t get much exposure at any time of the year due to their circumstances – for example, they might work at night or they might be unable to get outdoors every day. Sunlight shining through a window is usually insufficient to make vitamin D. People with darker skin pigmentation can also find it difficult to maintain levels of vitamin D.

Foods that contain lots of vitamin D are often not eaten every day, so many people supplement their diet with tablets that contain their daily dose. NHS guidelines are that in general everyone over age 5 should take 10mcg (400UI) Vitamin D per day from October – March. Those people who see very little direct sunlight or who find it difficult to maintain their vitamin D levels should take the supplement all year round. NOTE some people take calcium tablets that are already supplemented with vitamin D, so in that case need no further supplementation.
That said, individuals can be very variable in how much Vitamin D supplement they need so if in doubt see your doctor.

Does vitamin D protect us from COVID-19? So far the answer is maybe but there is not enough evidence to strongly support the suggestion. Studies are ongoing. However as already discussed there is plenty of evidence to suggest that you need to ensure that you get enough vitamin D regardless of COVID-19. Keep your levels up and you will benefit in lots of ways – if we find in the future it is good for prevention of COVID-19 infection, so much the better.

COVID Update October 13th: Shielding

Over the last few weeks during September & October, the number of COVID cases has been rising in some areas of the UK, and this situation is accelerating in a few hotspots, so we have been instructed that some areas would be ‘locked down’ by taking additional precautions to prevent the transfer of the virus from person to person. Full instructions are as follows:

Additional instructions for people living in England who are highly vulnerable have been published. This is the group of people who received a letter from their doctor or UK government during the first wave of infections telling them Shield themselves at home as they are at increased risk of experiencing more severe symptoms if they were to become ill with COVID-19.

This document replaces all earlier documents published on Shielding, and only applies to England. The advice is different depending on the risk level set in your local area by Gov.uk. (Medium, High or Very High – see link above)

 

For people living in the UK outside of England: The UK government has updated its instructions for people living in England to help prevent infection by COVID-19.

 

COVID Information for Patients Attending Manchester University NHS Foundation Trust (MFT)

MFT is the Trust that hosts the National Aspergillosis Centre (NAC) in Manchester, UK. MFT is present on 12 sites throughout Greater Manchester including Wythenshawe Hospital which is where NAC is located.

Just like most acute care hospitals in the UK, Wythenshawe and most other sites at MFT have undergone major changes in how they operate outpatient care during the COVID outbreak, and those changes have included how NAC operates so that we can ensure the safety of patients and staff.

For clarity and information MFT have produced a series of webpages that contain all the information you may need if you have an appointment to attend a clinic at any MFT site. The information is updated regularly.

Coronavirus (COVID-19) procedures and precautions for attending MFT as a patient

The Host, its Microbiome and their Aspergillosis.

Infection

For a very long time, medical science has assumed that infectious diseases are caused by the presence of a pathogen and weakness in the infected person or the host as it is often known, which allows the pathogen to grow and infect. The weakness could be for example a weakened immune system caused by a genetic illness or immune-suppressive treatment such as is used for transplant patients.

We assumed that inside our bodies there was mostly a sterile environment, and one reason we might become ill could be a pathogen getting into one of those sterile areas and then growing uncontrollably. One of those sterile area’s was our lungs – so 30-40 years ago most would have concluded that aspergillosis was caused by an Aspergillus spore getting deep into the lungs of the recipient and then managing to grow.

Microbiome

Around the year 2000 we started to be able to look at our internal spaces in more detail and identify any microbes that might be present, What was found was a surprise, for example, we could find many microbes; bacteria, fungi and virus’ growing in our lungs without causing any harmful symptoms. It is common to find Aspergillus fumigatus (ie the pathogen that we assume causes aspergillosis most of the time) present in the lungs of most of us where it lives without causing aspergillosis. How is that possible and what is the difference between that situation and the allergy & infections caused in the lungs of an aspergillosis patient?

We quickly learned that microbes could establish harmless communities, living in harmony with each other and with our immune system. This community was named the human microbiome and included all microbes who live within and on us. Huge numbers live in our gut, especially in our large intestine which is the last section of our digestive system to receive our food before it is ejected via the rectum.

Our Microbial Friends

It has emerged then that A. fumigatus can be controlled by its microbial neighbours (our microbiome) working in a tightly controlled partnership with our immune system.

The fungal pathogen interacts with the host to calm the host’s response to the pathogen and uses parts of the host’s immune system to do this. In this way the host and pathogen tolerate each other and do little harm, however, it has been demonstrated that if parts of the host’s fungal recognition system are not working then the host will initiate an aggressive inflammatory response. This is not unlike the situation in ABPA where one of the major problems is the host over-responding to the fungus.

We are also given an example of the microbiome controlling the host’s immune response to a fungal pathogen. Resistance to infection can be increased by the microbial population in the gut sensing a signal – presumably in food ingested by the host. This means that environmental factors can influence the rejection of a pathogen by its microbial neighbours – the message we might take from this is to look after our gut microbiome, and it will look after us. This also holds for the microbes in our lungs, where we have seen differences in the types and location of bacteria in the upper and lower airways that seem to be consistent with the microbiome controlling inflammation – the authors speculate that we need to look at what happens when we challenge these lung microbiotas with a highly inflammatory pathogen such as Aspergillus fumigatus.

The microbiome is also self-regulating as long as it is kept healthy. Bacteria can attack fungi, fungi can attack bacteria in an ongoing battle for food. Host pathogens can be eliminated completely from the microbiome by other microbes.

Different microbiomes in a different part of our body can interact and control diseases such as asthma (ie. lung microbiome interacting with gut microbiome) – so what you eat may influence the microbes in your gut microbiome and that can have an impact on your asthma, for example.

 

I must warn you that lots of the observations mentioned above are based on very few experiments so far, and mostly on animal model systems and Candida rather than Aspergillus so we must be cautious in our interpretation with regard to aspergillosis, however there are a few take-home messages worth bearing in mind.

  1. Most healthy people seem to have very healthy, highly diverse microbiomes – so look after yours with a well-balanced diet containing lots of plant material, lots of fibre
  2. Researchers seem to be turning our assumptions of what infection is on its head – they seem to be saying that inflammation causes infection, rather than infection causes inflammation.
  3. What you eat can have a direct impact on the amount of inflammation your body uses in response to what it perceives as a pathogen.

It can’t be that diseases like asthma and ABPA are caused by an unhealthy microbiome can it?

Current research seems to be suggesting that it may play a part, so the value of someone with aspergillosis doing what they can to promote a healthy community of microbes within themselves cannot be overstated.

What should I eat for a healthy microbiome? (BBC website)

Human Microbiome Project

Microbiome-mediated regulation of anti-fungal immunity

July 31st: Update on UK government guidelines for COVID-19 precautions, limited lockdown

Applies to the North West of England: For full details click here

Those people shielding in those areas should consult their local medical services for information in continuing or extending shielding,

An outbreak of coronavirus (COVID-19) has been identified in parts of Greater Manchester, East Lancashire, and West Yorkshire. The government and relevant local authorities are acting together to control the spread of the virus. From 31 July 2020, if you live in these parts of Greater Manchester, East Lancashire and West Yorkshire, you should follow these rules when meeting people who you do not live with. Separate guidance advises on the similar rules imposed in Leicester.

Affected local areas

  • Greater Manchester:
    • City of Manchester
    • Trafford
    • Stockport
    • Oldham
    • Bury
    • Wigan
    • Bolton
    • Tameside
    • Rochdale
    • Salford
  • Lancashire:
    • Blackburn with Darwen
    • Burnley
    • Hyndburn
    • Pendle
    • Rossendale
  • West Yorkshire:
    • Bradford
    • Calderdale
    • Kirklees

Local restrictions

Social contact

If you live in one of the affected areas, in order to help prevent the spread of coronavirus, you should not:

  • meet people you do not live with inside a private home or garden, except where you have formed a support bubble (or for other limited exemptions to be specified in law).
  • visit someone else’s home or garden even if they live outside of the affected areas.
  • socialise with people you do not live with in other indoor public venues – such as pubs, restaurants, cafes, shops, places of worship, community centres, leisure and entertainment venues, or visitor attractions. You may attend these venues with people you live with (or are in a support bubble with), but should avoid interaction with others. If you run such a business, you should take steps to ensure people do not interact with people they do not live with, in line with COVID-19 Secure guidance.

The government will pass new laws to enforce the changes to meeting people in private homes and gardens. The police will be able to take action against those that break these rules, including asking people to disperse and issuing fixed penalty notices (starting at £100 – halving to £50 if paid in the first 14 days – and doubling for subsequent offences).

Business closures

In Blackburn with Darwen and Bradford, the following premises must remain closed by law:

  • indoor gyms
  • indoor fitness and dance studios
  • indoor sports courts and facilities
  • indoor swimming pools, including indoor facilities at water parks

Changes in restrictions

Does my household include close family members?

Your household – as defined in law – is only the people you live with. If you have formed a support bubble (which must include a single adult household i.e. people who live alone or single parents with dependent children aged under 18) these can be treated as if they are members of your household.

What will be illegal?

It will be illegal for people who do not live together to meet in a private home or garden, except for limited exceptions to be set out in law. You should not host or visit people you do not live with, unless they are in your support bubble. If you live in the affected areas, you should not visit someone’s home or garden regardless of whether this is in or outside of the restricted area.

Can I still meet indoors with people in my support bubble?

Yes. Where people from single adult households (people who live alone or single parents with dependent children aged under 18) have formed a support bubble with another household, they can continue to visit each other, stay overnight, and visit other public places as if they were one household.

Can I still meet people outdoors?

In line with the national guidance, you can continue to meet in public outdoor spaces in groups of no more than six people, unless the group includes only people from two households. You cannot meet people you do not live within a private garden.

At all times, you should socially distance from people you do not live with – unless they are in your support bubble.

I live in this area. Can I still meet with my family and friends to celebrate Eid?

Due to higher rates of infection, if you live in this area you should not host or visit friends and family in each other’s homes or gardens. It will shortly be illegal to do so, unless specific exemptions apply. You also should not meet friends and family in other venues – including restaurants or cafes.

Up to two households, or six people from any number of households may meet outdoors (excluding people’s gardens) where there is a lower risk of infection. If you do so, you should still socially distance from those you do not live with, and avoid physical contact.

You may attend a mosque or other place or worship, where Covid-19 Secure guidance applies, but you must socially distance from people outside of your household. This means maintaining a distance of 2 metres, or 1 metre with mitigations (such as wearing face coverings). We recommend at this time that, if possible, prayer/religious services take place outdoors.

Can I still go to work in this area?

Yes. People living inside and outside of this area can continue to travel in and out for work. Workplaces must implement Covid-19 Secure guidance.

I live in this area. Can I still go to cafes, restaurants, the gym and other public places?

Yes. But you should only go with members of your own household – even if you are going outside of the restricted area.

I live in the area. Can people from outside of the lockdown area visit me at my house?

No. This will be illegal.

Do I still have to shield if I live in this area?

Clinically extremely vulnerable people will no longer have to follow the shielding guidance from the 1 August, unless they live in Blackburn with Darwen in the North West and other local affected areas across England where shielding continues.

Can I visit a care home?

You should not visit friends or family in care homes, other than in exceptional circumstances. Care homes should restrict visits to these circumstances.

Can I still have my wedding if it’s in the lockdown area?

Weddings and civil partnership ceremonies in these areas can still go ahead. No more than 30 people should attend a marriage or civil partnership, where this can be safely accommodated with social distancing in a COVID-19 secure venue. Further guidance can be found here.

Large wedding receptions or parties should not currently be taking place and any celebration after the ceremony should follow the broader social distancing guidance of involving no more than two households in any location or, if outdoors, up to six people from different households.

Can I travel outside of the lockdown area to attend a wedding ceremony?

Yes.

Can I travel into the lockdown area to attend a wedding ceremony?

Yes. Weddings should be limited to no more than 30 people and subject to COVID-19 Secure guidelines.

People living outside the lockdown areas may travel into the areas to attend a wedding, but should not go into a private home or garden.

Can I still visit a place of worship in the lockdown area?

Yes, but you must socially distance from people outside of your household. This means maintaining a distance of 2 metres, or 1 metre with mitigations (e.g. face coverings). We recommend at this time that if possible prayer/religious services take place outdoors.

Can funerals still take place in the lockdown areas?

Yes. Funerals should be limited to no more than 30 people and subject to COVID-19 Secure guidelines.

People living outside the lockdown areas may travel into the areas to attend a funeral.

Can I holiday in the lockdown area, or visit shops, leisure facilities, or cafes in it?

Yes. However, you must avoid socialising with people indoors when doing so.

Can I travel in a car with someone I do not live with?

You should try not to share a vehicle with those outside your household or social bubble. If you need to, try to:

  • share the transport with the same people each time
  • keep to small groups of people at any one time
  • open windows for ventilation
  • travel side by side or behind other people, rather than facing them, where seating arrangements allow face away from each other
  • consider seating arrangements to maximise distance between people in the vehicle
  • clean your car between journeys using standard cleaning products – make sure you clean door handles and other areas that people may touch
  • ask the driver and passengers to wear a face covering

The Department for Transport has provided specific guidance on using private vehicles. Please see their guidance on private cars and other vehicles for more information on car sharing and traveling with people outside your household group.

Published 31 July 2020
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