COVID-19 and Vitamin D

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In early September, a study published in JAMA Network raised the stakes on the importance of adequate Vitamin D levels – there may be an association between lower Vitamin D levels and CoVID-19. ​ In this study, researchers from the University of Chicago Medical School (one of the best in the country) looked at over 4000 cases of CoVID-19 and did a retrospective analysis. In the end they recruited 489 patients who had a measured Vitamin D level within a year but more than 14 days before CoVID diagnosis. Interestingly, the vast majority of these patients were non-white women. ​ Those with deficient Vitamin D levels had a 19% incidence of CoVID-19 vs 12% in those with sufficient Vitamin D levels. This finding corroborates what we have long known about Vitamin D: it is important for optimal functioning of the innate immune system. ​ There are many things about this study that make it quite powerful but, as usual, there are also many unanswered questions. I am happy to dive into the gritty details of confounding variables, etc. but for now, I want to leave you all with this take home point: timing is everything. We all could use adequate Vitamin D levels, and now is the optimal time. ​ Seventy percent of Americans will, at some point in their lifetime, be Vitamin D deficient. This deficiency can be attributed to many things: Celiac disease, obesity, diabetes, age, sheltering at home, living in the God-forsaken Northeast Corridor, and other things. While very high doses of Vitamin D can be harmful, modest doses of supplemental Vitamin D may provide some protection against the risk of developing COVID-19. More importantly, low doses of Vitamin D most certainly carry very little harm. ​ Ideally, we would know your Vitamin D level before you begin a supplement. However, insurance coverage for Vitamin D testing is spotty without a known deficiency. We have seen labs charge $300-400 for the test. ​ In the aforementioned study, inadequate levels were defined as a 25-hydroxycholecalciferol level less than 20 pg/ml, or a 1,25 dihydroxycholecalciferol less than 18 pg/ml. These are really low levels. Even pre-CoVID-19, most clinicians would say that any 25-hydroxycholecalciferol under 30 pg/ml warranted supplementation given Vitamin D’s role in calcium absorption and innate immunity. So, my recommendation to OUR practice patients (please consult with your own doctor), is to get levels checked IF you have had vitamin D deficiency in the past (the testing is covered in this setting). ​ If you are not sure of your level, and currently do NOT take a Vitamin D supplement, adding 800-1000 IU per day of Vitamin D3 MAY be beneficial and is most likely NOT harmful. This is especially true as we see our gloriously long summer days dwindling. Less sun exposure means less skin conversion to active Vitamin D levels. Basically, now is as good a time as any. ​ Remember, there really is such a thing as TOO much. More is not necessarily better, and may be harmful. ​ In my house, we have spent a lot of our two decades of parenting talking about risk-reward in terms of behavior; the risk of getting caught driving your mom’s car vs. the very temporary reward of impressing a lovely young lady, for example. Nowhere has this concept of low risk vs. possible benefit been more important than in medical interventions in the era of CoVID-19. Should we take supplements? Should we get our blood types checked? Should we gargle with peroxide? Deciphering the pros and cons of these scenarios is hard but it really does boil down to a simple series of questions. Does the proposed intervention show possible benefit? What is the risk? Is the relative risk low compared to the benefit? ​ Give us a call or send us a portal message if you have further questions. We're here to help.

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MMR Booster Series Immunizations

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In June, we began following news that a relatively low-risk action may decrease our risk of serious illness or death if infected with SARs-CoV-2, the virus that causes the disease known as CoVID-19. In a paper submitted to Dr. Fauci and NIAID in March, and updated in May, several researchers from world.org describe powerful evidence that the MMR vaccine confers protection against severe disease and death from CoVID-19. This is correlative data, based on well-established, published epidemiological data.

What does this data mean for us? Well first, MMR immunity does NOT protect you from getting CoVID-19 (read that aloud if you need to) – it changes nothing about the urgent need to social distance, mask, hand-wash, and quarantine. But beyond that, understanding what MMR immunity CAN do for you requires some background. And some action. FAST FACTS: Are you a skimmer? Here are the essentials:

• New and emerging research suggests that MMR (Measles, Mumps, Rubella) immune status appears to correlate with a patient's ability to recover from CoVID-19. Higher MMR vaccine use has reduced some countries' rates of death (but not rate of infection).

• MMR immunity does not mean immunity to CoVID-19 and does not reduce your ability to contract or spread CoVID-19. Those with MMR immunity (such as a recent MMR booster shot) should not change precautions and must continue vigilant social distancing, masking, and hand-washing.

• Call our office at 610-363-0100 to request a blood test to check MMR status, or to request an MMR booster series. Both can be done in our outdoor tent (no need to come inside). Some patients are not eligible due to contraindications.* Insurance coverage will vary; we'll help you determine out-of-pocket expenses.

First, background. MMR stands for Measles, Mumps, and Rubella. This vaccine protects against three of the most highly contagious viruses known. It was introduced in 1971. Recently, we have seen more outbreaks of measles and mumps as some people and communities withhold this vaccine. This discussion is for a different time. Suffice it to say, for those that ascribe to science, any theory that MMR leads to autism has been debunked repeatedly and for a very long time. If you are fuming mad at this statement, please stop reading now.

Scientists have now compared death rates from CoVID-19 in countries that had robust booster programs for MMR, against countries that had not. It turns out that some of the countries with the LOWEST death rates had the highest MMR booster rates, and vice versa. For example, Madagascar, a country of 26 million people, vaccinated 26% of its population against MMR in 2019 and already had a high rate of immunity to MMR. They have had ZERO deaths. Hong Kong did the same in 1997 for all 19 year-olds, and continued an aggressive schedule of immunization into 2020. Despite being 500 miles from Wuhan, the epicenter of CoVID-19, they have had just FOUR deaths.

On the other end of the spectrum, Belgium, with a population 54% higher than Hong Kong’s had nearly 8,000 deaths. They had not begun giving two doses of the combined vaccine until 1995. Italy, the European country with one of the lowest rates of MRCV (measles/rubella combined vaccine) has, as we all know, one of the highest death rates.

Lastly, consider the USS Roosevelt. Of the 1,102 on board that tested positive for CoVID-19, only 7 had been hospitalized with ONE death. The US military gives all new recruits MMR regardless of immunization history.

Twelve days after this paper was submitted, Cambridge University scientists released data that pointed to similarities between SARS-CoV2 and Rubella, suggesting the reasoning for the above findings.

Keep in mind that more research is being done as we speak, but these are excellent and reliable sources. There are always confounding variables and questions to work through but here is the kicker: in this particular case, we can take a relatively harmless action that may have a tremendous benefit. As individuals, we can update our MMR status, and we can do it now.

First, this is a good opportunity to remind everyone what the current CDC recommendations are for MMR boosters. Let's review:

• Individuals born before 1957 most likely have natural immunity to MMR. Similarly, those who know for certain they had measles, mumps or rubella disease have natural immunity.

• Women who have given birth and had evidence of immunity during their prenatal testing or a booster immediately after delivery, are up to date.

• Anyone who does not fall into the above — ie, all men born after 1957, and women who have not had titers confirmed in routine prenatal testing (ie never been pregnant) — need evidence of immunity to MMR.

• Evidence of MMR immunity can be in the form of documentation in your medical records of two doses of MMR, or serologic evidence (blood test).

Those without evidence of immunity, should consider getting an MMR booster series. This is a CDC adult immunization schedule recommendation. Exceptions are pregnant patients, those with blood disorders, and the immunosuppressed. After one dose, 93% of complete immunity is achieved. After two doses, 97% is achieved. It takes about 10-14 days after immunization to have detectable titers. And while there is little harm to getting a booster even if you have MMR immunity, people who are already MMR immune may have a local reaction (redness, swelling etc.). The CDC recommendation is completely independent of the above information about MMR and CoVID-19.

I am encouraging all patients to have a discussion with your provider and take one, or both, of two potentially beneficial steps: 1) Check your MMR immune status with a simple blood test. We can do this here at the office as an outdoor tent service (you don't have to come inside the office). Simply call us (610-363-0100) to set up an appointment. If you are immune to MMR, a booster is not needed and would not offer any additional protection. It is presumed that patients born before 1957—pre-vaccine era—would have been exposed to measles and have natural MMR immunity. However, even those born prior to 1957—especially healthcare workers—should check their status.

2) If you are not MMR immune, and do not have any of the contraindications* listed, I would get an MMR booster series. This can also be done in our outdoor tent – no stepping foot inside the office. Many people will get MMR boosters during their lifetime. If you were going to do it at some point, this is the time. This is the moment.
Of course, every vaccine has the POTENTIAL for side effects. It all comes down to weighing the risks (less than 1% chance of reaction) against the benefits. Every individual has to do that math for themselves. Just, please use actual science to decide. Financially, some insurances are covering testing but not boosters, and some are covering boosters but not testing. Check with yours. Medicare does not cover it. In our practice, we will let you know the potential out-of-pocket costs for testing and MMR immunization if not covered by insurance.

*Patients who are pregnant or unsure of pregnancy status, those with blood disorders, and the immunosuppressed, would not be candidates for the MMR booster, but we can still check your MMR immune status. Call us to discuss your situation individually.
Now, what about the fact that this is all new, and only correlated data? Well, the MMR vaccine has been protecting patients since 1971. There is an extremely low risk of harm, a benefit even absent the CoVID connection, and the worst-case out-of-pocket cost is hovering around $90 per dose, which most people would have spent on this at some point anyway to update their vaccines before travel or other occasions. This is one of those true, rare, "why-not" moments in the medical field. And I'm so glad research has revealed its potential to help this crisis.

Finally, there are a few last things I need you to hear again:
1) MMR immunity has NOTHING to do with immunity to Coronavirus. It does not make you less likely to get CoVID, it is not an antibody for CoVID, and it does not make you less contagious if you have CoVID. MMR immunity just may afford some protection against the most serious consequences of COVID-19.

2) This layer of protection does nothing to help your neighbor. You are just as able to spread Coronavirus to others, and no actions should change when it comes to social distancing, masking, hand-washing, or quarantining at home. The biggest risk of celebrating personal CoVID victories—antibodies, MMR immunity, or anything else—is that we will ease-up on precautions and expose those who are still just as vulnerable.

3) Patients with ANY signs of sickness must stay home. No exceptions.
I look forward to a flurry of phone calls and portal messages, and my staff is already preparing. If you have an appointment coming up for something else, ask about MMR at that appointment and we'll gladly handle it while you're here. The time to act is now.

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Antibody Testing Consultations

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Our office now consults with patients about the SARS-CoV-2 Antibody (IgG) test. This is not a test for active infection, but the test is great news because:

• We need to know who has antibodies to SARS-CoV 2 so that we can understand what level and duration of immunity these antibodies provide. If immunity is conferred, we can choose our first-line workers with this in mind.

• We need antibody testing to help in vaccine work.

• We need to work on using plasma donations as treatments for critically ill COVID-19 patients.

• We need to know how many of us have antibodies to help determine the potential level of herd immunity in the community at present.

Yes, we are cautiously optimistic about any new test; this article summarizes the data from University of Washington very well. ​ ABOUT THE TEST: The test is NOT FDA approved, but has emergency-use authorization and has amazing, amazing promise – nearly 100% sensitivity and 99% specificity. Translation: it really does not miss truly positive patients unless testing is done too soon*, AND if antibodies are found, they are 99% of the time due to this COVID-19 virus. This is not, I repeat, NOT a test for those who are currently sick with COVID-19 symptoms. ​ *If the test is done less than 14 days after the onset of symptoms, it MAY NOT be positive. GETTING THE TEST: This blood test must be ordered by your provider. In our practice, the workflow is:

• Call our office at (610) 363-0100. Call once; leave a message (one message) if you get our answering machine. Repeat calls will only increase volume, and will not speed up our reply.

• Set up a visit (televisit or in-office) with one of our providers. We will discuss your request and the implications of the results, positive or negative. (If you are in the office, we can draw your blood right then.)

• Results will take at least 2 to 3 days. We will notify positives immediately, If you don't hear right away (within three days), you can assume you are negative, though we will still let you know as soon as we are able.

IMMUNITY: If you are found to have antibodies, you can reasonably expect, based on past viruses that have been studied, that you have some level of immunity. The degree and duration will be determined over time. If you are a balloon popper, holding your breath and sharpened pin, just dying to post a comment about the S. Korean cases of "reinfection," please don't. No one in the respected infectious disease community believes these cases were truly reinfections. Work is being done to identify the causes for repeat positive testing (faulty testing, persistent viral debris etc.) “Does a positive antibody test mean I can ignore social distancing rules?” ABSOLUTELY NOT. First, there are millions of unknown and vulnerable people without antibodies. It is our duty to do everything right to protect those people. Second, antibody presence while encouraging does not guarantee full or permanent immunity. Caution must prevail. And third, we all need to accept the fact the some version of social distancing is here to stay—antibodies or not. WHO SHOULD GET THE TEST? The test is for the following:

• people who had or think they had COVID-19 AT LEAST 2 weeks ago.

• people who may be asymptomatic carriers.

If you add those two criteria up, EVERYONE except for those who are currently or recently ill, is a candidate. So practically speaking; if you know or suspect you had COVID-19 at least 14 days ago, or are asymptomatic but concerned about exposure, you are eligible for testing. This applies most critically to those essential workers who may be exposed every day. Otherwise, if you are not an essential worker, you should still be tested, but to manage testing supplies and wait times, you could wait a week or two to call for your antibody consultation. ​ INSURANCE AND COPAYS: We will draw your blood here and send to the proper lab based on your insurance (Quest, or LabCorp for IBC patients). All uninsured/underinsured costs should be covered by the CARES act; the out-of-pocket cost is $55. We will not be charging fees for your visit with our providers. A few final, important notes: KIDS/HEALTHY STEPS: I only speak for patients of any of the providers at CMMD and Associates. I learned about 27 years ago NOT to speak for my husband so if your child goes to HSP, you need to check in with them. NEW PATIENTS: While I am flattered by the flurry of new patient inquires this news has brought, please be kind to your long-time docs — call them. Give them a chance to respond to your questions before switching to another practice. You MUST have a visit with one of us before we can authorize the test. It can be a televisit or in office visit. Yes, we can see you soon.
My team is ready to answer your calls. We will not stop until we have accommodated every possible patient in our practice. If I personally have to talk to patients 24 hours a day to get this done (provided I can still function soundly) I will, and I know my team is with me. ​ -Christine & Team

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