Dear Premier Ford:
re: A Way Out of Pandemic Dilemma
I appreciate the difficult task that you and the Province of Ontario have in managing the COVID-19 pandemic. You have to protect the population, particularly our most vulnerable members, and you have to protect the economy and society at large. May I suggest some steps to deal with the competing interests.
1. Focus on the capacity of our health care system, mainly hospitals, to handle COVID rather than the number of citizens being infected. With what the world has learned since January, we should be able to manage the numbers who become severely ill even if the total number of cases increases sharply. An inspection of the graphs of cases, hospitalizations and deaths suggests that Ontario can handle a substantial rise in cases and still protect the hospitals and the most vulnerable.
2. Ensure that the population is vitamin D sufficient. I have had an interest in this substance for several years and have come to appreciate its importance to the overall health of individuals. Accordingly, it is more than just a vitamin required to prevent rickets. It is now recognized as a pro-hormone that can affect virtually every cell in the human body. In the context of the current pandemic, its most interesting features include an anti-viral effect and the ability of modulate the inflammatory response to viral infections. Going into this pandemic there was substantial circumstantial evidence that led me and others to suggest that vitamin D sufficiency was crucial to our ability to deal with this disease. Since January there has been an abundance of evidence that indicating that vitamin D deficiency promotes COVID-19 and that supplementation with this compound would reduce both the prevalence and severity of the disease. Please take 80 minutes and watch the excellent video on vitamin D and COVID at https://www.youtube.com/watch?v=8UzpvtRqleY&feature=youtu.be. If you don’t have the time, please have a staff member watch it and summarize it for you; alternatively you could take just a few minutes and read my May 19 blog at https://vitamindcovid.blogspot.com/2020/05/vitamin-d-covid-19-and-me.html and the Sep 10 update at https://vitamindcovid.blogspot.com/2020/09/vitamin-d-and-covid-19-update.html.
Of the many recent reports related to COVID treatment the one that impressed me the most was the August 29 publication by Castillo et al in the Journal of Steroid Biochemistry and Molecular Biology. This small prospective trial compared 50 calcifediol-treated subjects with 26 control subjects in Cordoba, Spain. Among those treated with calcifediol only one (2%) required intensive care compared with 13 (50%) of the control group; there were no deaths in the calcifediol group and two in the group that did not receive this form of vitamin D.
If we were to bring the population of Ontario up to vitamin D sufficiency, it seems possible to bring the burden of COVID-19 down to a level that may well be acceptable to the population at large. Optimistically, the Infection Fatality Ratio (deaths divided by infections) could be ~0.02 to 0.06% with vitamin D sufficiency and the judicious use of calcifediol (faster acting form of vitamin D) and dexamethasone in our most seriously ill patients. I believe that the risk of dying due to COVID-19 could be reduced to be that of seasonal influenza. Under such circumstances, our society and economy could be opened up to that during a serious outbreak of seasonal influenza. In saying this, I do not take seasonal influenza lightly as the number of deaths is far from trivial. At the same time, the adverse effects brought on by our response to COVID-19 are very substantial. These include but are not limited to poor mental health, cancer, opioid deaths, economic disaster, poor physical health, etc; I have addressed some of these in my June 7 blog entry at https://vitamindcovid.blogspot.com/2020/06/human-and-economic-cost-of-covid-19.html. Unfortunately you (we) are in the position of having to balance the adverse effects of COVID-19 against the adverse effects of its treatment- a no win situation for sure.
In order to ensure that residents of long-term care homes are protected, the Province should consider acquiring an adequate stock of vitamin D for them prior to recommending it to the public. Patients needing vitamin D on admission to hospitals should be given calcifediol. Vitamin D tablets are very inexpensive; it would cost just pennies a day per person. It is also very safe. The dose at which adverse effects can be observed is far in excess of that required to prevent or mitigate COVID infections. This compares very well with the thousands of dollars/day it costs for a hospitalized patient.
3. Ventilation of indoor facilities. I understand that the major route of COVID transmission is through inhalation of virally laden air as would be the case in poorly ventilated and crowded rooms. In order to address this the Province has chosen to limit the numbers of people permitted the various establishments. May I suggest the alternative of setting standards for ventilation by area- a certain number of air exchanges per hour. This might allow more people in a room if the air flow was sufficient to dilute/take away exhaled virus particles. I could imagine a restaurant with exhaust tubes above each table collecting exhaled air and expelling it from the building; it this were connected to a heat recovery ventilator this would minimize the added heating expense for the restaurant.
4. Alternatives to mechanical ventilation. We are concerned about overwhelming our hospitals with COVID patients because their lung infections render them hypoxic and in respiratory distress. Accordingly, there has been much effort put into ensuring that they have a sufficient supply of mechanical respiratory ventilators and the personnel to operate them. In the May 15 issue of the Journal of Wound Care, the authors describe using hyperbaric oxygen chambers to treat hypoxia due to COVID-19. As there are numerous hyperbaric chambers in our cities, there would be substantial capacity to relieve our hospitals should it become necessary. In the unlikely event that all of these were insufficient, it should be possible to commandeer a few jet aircraft and pressurize them with oxygen enriched air to create makeshift hyperbaric chambers. This is not an original idea as it has been suggested by others.
In closing, I would like to thank you and your colleagues for all your efforts to keep our most vulnerable family members safe. My 98 year- old aunt is in a Toronto long-term care home and has survived a bout of COVID-19.
Your sincerely,
Kanji Nakatsu
