A STUDY OF SERUM VITAMIN D LEVELS IN COVID

19 PATIENTS AND ITS ASSOCIATION WITH

SEVERITY OF THE DISEASE
Arun Kumar Alagesan1, Kannan Rajendran1, Vikrannth V1, Vinod Raghavan1, Tirumalasetty Sriharsha1, Raghav J1
1
Department of General Medicine, Saveetha Medical College and Hospital, Tamil Nadu, India.

DOI: 10.47750/pnr.2022.13.S09.1114

Background: Vitamin D recently has been reviewed as one of the factors that may affect the severity in COVID 19 infection.
Despite its role in calcium and phosphorus metabolism, vitamin D has multiple effects on cell proliferation, differentiation,
apoptosis, immune regulation, genome stability and neurogenesis. Recent studies have also found that vitamin D deficiency is
closely associated with infectious diseases, diabetes, cancers, autoimmune diseases and cardiovascular diseases.

Materials and methods: The current study was undertaken for a period of 6 weeks. The study enrolled 125 COVID 19 positive
patients, 60 in group A (non-hypoxic) and 65 in group B (hypoxic but not requiring ICU admission). Participants were of age
group 20-60 years. Serum levels of 25(OH) vitamin D were measured. Serum vitamin D concentration was estimated by using
CLIA (Chemiluminescence Immuno Assay) technique. Standard statistical analysis was performed to analyze the differences.

Results: The mean level of vitamin D was 31.87 ng/ml in group A and 18.11ng/ml in group B, the difference was highly
significant (p value <0.0001). Vitamin D level is markedly low in group B patients. In hypoxic patients (group B), 60% were
having deficient serum vitamin D level and 33.8% were having insufficient level of serum vitamin D.

Conclusion: In our study in comparison to non-hypoxic group, vitamin D level is low in hypoxic group. Vitamin D
supplementation may help for COVID19 patients.

Keywords: Vitamin D, Deficiency, Covid 19

Introduction
India was under a grave threat from the second wave of the COVID-19 pandemic particularly in the beginning of
May 2021. The situation appeared rather gloomy as the number of infected individuals/active cases had increased
alarmingly during the months of May and June 2021 compared to the first wave peak. This novel corona virus
outbreak has burdened India’s economic, medical and public health infrastructure. In the current pandemic
situation, a myriad of strategies would be extremely critical to battle the rapid virus spread and to treat the
infection.

Corona viruses belong to coronaviridae family in the nidovirales order. Corona represents crown like spikes on
the outer surface of the virus, thus it was named as a corona virus. Corona viruses are minute in size (65-125nm
in diameter) and contain single stranded RNA as a nucleic material. The subgroup of corona viruses’ family are
alpha, beta, gamma and delta corona virus. Covid 19 can cause acute lung injury (ALI) and acute respiratory
distress syndrome (ARDS) which leads to pulmonary failure and result in fatality. These viruses were thought to
infect only animals until the world witnessed a severe acute respiratory syndrome (SARS) outbreak caused by

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SARS- COV, 2002 in Guangdong, china.1 Only a decade later, another pathogenic coronavirus known as middle
east respiratory syndrome corona virus (MERS-COV) caused an endemic in middle eastern countries.2 Recently
at the end of 2019, Wuhan an emerging business hub of China experienced an outbreak of a novel corona virus.
This virus was reported to be a member of the beta group of corona viruses. The novel virus was named as 2019
novel corona virus (2019-n cov) by Chinese researchers. The international committee on taxonomy of viruses
(ICTU) named the virus as SARS COV2 and the disease as covid 19. 3,4

The human-to-human spreading of virus occurs due to close contact with an infected person, exposed to coughing,
sneezing, respiratory droplets or aerosols. These aerosols penetrate the human body(lungs) via inhalation through
nose or mouth.

Vitamin D deficiency is a particularly important public health issue in the general population. Emerging research
supports the possible role of vitamin D against cancer, heart disease, fractures, infection, autoimmune diseases,
influenza, type 2 diabetes and depression.5

Vitamin D in the human body is mainly derived from skin after ultraviolet light exposure and from dietary sources.
Vitamin D is derived from 7-dehydro cholesterol, which is converted in the skin by ultraviolet light band B to
vitamin D3 (cholecalciferol), an inactive precursor. More than 90% of systemic vitamin D originates from the
skin and around 10% from food intake. There are two main forms of vitamin D, vitamin D3(cholecalciferol) and
vitamin D2(ergocalciferol). Following the absorption from intestines or the synthesis by skin, vitamin D is
transferred to the liver where it is metabolically converted in to 25(OH)D in the liver, 25(OH)D has a further
metabolic conversion in the kidney. Calcitriol(1,25-(OH)2D) is the active form of vitamin D which is generated
by 1alpha hydroxylase enzyme present in kidney. The biological effects of vitamin D are divided in to two
categories: First in, calcium and phosphorus metabolism, considered the classical pathway and second, the non-
classical or alternative pathway that mainly affects immune function, inflammation, antioxidation and anti-
fibrosis, as well as inhibitory effects on many kinds of malignancies.6

Vitamin D plays a role in various infectious processes (eg: tuberculosis), respiratory tract infections and
influenza,7,8,9 chronic obstructive pulmonary disease (COPD) exacerbations,10,11 cystic fibrosis, sepsis12 and
human immunodeficiency virus (HIV).13 Calcitriol acts through the vitamin D receptor (VDR), a polymorphic
nuclear receptor that modulates the expression of genes involved in immune function and cytokine production. 14
The VDR and CYP27B1 are present in immune cells and bronchial and pulmonary epithelial cells , among others
and is upregulated following the ligation of specific toll like receptors by extracellular pathogens, implicating
vitamin D in innate immunity.15 By binding to VDR, calcitriol induces several endogenous antimicrobial
peptides(AMP) in human monocytes, neutrophils and epithelial cells (eg: cathelicidin IL-37, alpha defensing, beta
defensing and neutrophil gelatinase associated lipocalcin) and upregulates nitric oxide synthase. 16 AMPs inhibit
infection by bacteria, viruses and fungi, while NO synthase augments bacterial killing by upregulating the
oxidative burst in activated macrophages.17 Vitamin D may also induce a T helper 2 based response, characterized
by high immunoglobulin IgE and eosinophilia, to combat extracellular infections by parasites, protozoa and
fungi.18,19

Materials and methods

The current study was undertaken as continuous hospital based cross sectional comparative study of 6-week
duration. The study proceeded with the enrollment of eligible patients after obtaining due permission from the
Institutional scientific Review Board and Institutional Ethics Committee. An informed and written consent was
obtained either from the participants himself or their first degree relative. Participants were covid 19 patients of
age group 20-60 years who were admitted in tertiary care hospital during the study span of 6 weeks. The study
included 125 subjects and all subjects were followed till discharge. Two groups of covid 19 patients, Group A
who were non hypoxic and Group B who were hypoxic and not requiring mechanical ventilation were included
in the study.

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Non hypoxic covid 19 patients have Spo2 greater than 94%. Hypoxic covid 19 patients have Spo2 of 80-94% in
room air, Pao2/Fio2 of 300-500 mmHg and pneumonitis on chest Xray/ ground glass opacities on CT chest.

Lactating and pregnant females, diabetic and hypertensive patients, chronic renal disease patients on dialysis,
patients on chemotherapy, patients with chronic obstructive airway disease, chronic liver disease, cardiac disease,
patients above 60 years of age and those who were under treatment with vitamin D supplements were excluded
from the study.

All covid 19 patients who got admitted during the study period of 6 weeks were evaluated at triage and advised
admission to dedicated covid wards accordingly. Non hypoxic COVID 19 patients were advised admission in
isolation wards. Hypoxic COVID 19 patients were advised admission in high dependency unit. Our study
compared the vitamin D levels among non-hypoxic and hypoxic COVID 19 patients.

A 5ml of blood was collected in a regular red top vacutainer irrespective of when the last meal was taken. The
sample was centrifuged within one hour of collection. Serum vitamin D was estimated using CLIA
(Chemiluminescence Immunoassay) technique. The values of serum vitamin D were expressed in ng/ml.

Although there are different methods and criteria on defining vitamin D levels, the criteria holic proposed has
been widely accepted. In this proposal, it is suggested as vitamin D deficiency if the level of 25(OH)D in
circulating blood in human is less than or equal to 20ng/ml, insufficiency if between 21 to 29 ng/ml and sufficiency
if greater than or equal to 30ng/ml.20

Data obtained were compared between non hypoxic and hypoxic covid 19 individuals using Pearson chi-square
test. The serum vitamin D levels were also categorized gender wise. Statistical analysis was done using IBM –
SPSS 20 for Windows statistical software.

Table 1: Vitamin D level in non-hypoxic and hypoxic patients

COVID CATEGORY

Non-Hypoxic Hypoxic

Standard Standard
Mean Mean
Deviation Deviation

SERUM VIT. D
31.87 14.71 18.11 7.83
(ng/ml)

Table 2: Age wise distribution of participants

AGE GROUP Frequency Percent

<20 4 3.2

21-30 13 10.4

31-40 35 28

41-50 38 30.4

51-60 35 28

Total 125 100.0

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 Table 3: Sex distribution of participants

SEX Frequency Percent

Male 74 59.2

Female 51 40.8

Total 125 100.0

Table 4: Association of category of vitamin D levels between non hypoxic and hypoxic patients

COVID CATEGORY * SERUM VIT.D Crosstabulation

SERUM VIT.D
COVID
Total P value
CATEGORY Deficient Insufficient Sufficient

9 19 32 60
Non hypoxic
15.0% 31.7% 53.3% 100.0%

39 22 4 65
Hypoxic <0.0001
60.0% 33.8% 6.2% 100.0%

48 41 36 125
Total
38.4% 32.8% 28.8% 100.0%

*Pearson Chi-square test (p value <0.05 is significant)

Figure 4: Bar chart representing category wise comparison of vitamin D levels between non hypoxic and
hypoxic patients
45
39
40
35 32
30
22
Count

25
19
20
15
9
10
4
5
0
NON HYPOXIC HYPOXIC
COVID CATEGORY
SERUM VIT.D Deficient Insufficient Sufficient

Table 5: Comparison of serum vitamin D levels among non hypoxic and hypoxic COVID 19 patients between
both genders

SEX SERUM VIT.D Total P value

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 COVID
Deficient Insufficient Sufficient
CATEGORY

Non hypoxic 6 14.6% 12 29.3% 23 56.1% 41 100%

Male <0.0001
Hypoxic 18 54.5% 11 33.3% 4 12.1% 33 100%

Non hypoxic 3 15.8% 7 36.8% 9 47.4% 19 100%

Female <0.0001
Hypoxic 21 65.6% 11 34.4% 0 0.0% 32 100%

*Pearson Chi-square test (p value <0.05 is significant)

Results and discussion

The mean serum vitamin D level in non-hypoxic patients (group A) was 31.87 ng/ml and in hypoxic patients
(group B) was 18.11 ng/ml (Table 1), the difference was significant with a p value of <0.0001. Vitamin D level is
low in group B patients. The maximum number of patients were in age group 41-50 years (30.4%) (Table 2).
Majority of the patients were male (59.2%) (Table 3). There is a statistically significant association between covid
severity and serum vitamin D level (Table 4). In hypoxic patients 60% were having deficient serum vitamin D
level and 33.8% were having insufficient level of serum vitamin D level (Figure 4). There is statistically significant
association in covid category between serum vitamin D level in both gender (Table 5).

This study revealed the importance of low vitamin D level and it’s association with severity of covid 19 infection.
Our study shows that in hypoxic patients, 60% were having deficient serum vitamin D level and 33.8% were
having insufficient level of serum vitamin D level.

Alipio et al conducted a multinomial logistic regression to investigate the association between serum 25(OH)D
level and clinical outcomes of 212 cases with laboratory-confirmed infection of SARS–CoV2. The author reported
that a decrease in serum 25(OH)D level could worsen clinical outcomes of COVID-19 patients.21

A study done by Ilie et al found significant relationships between low vitamin D levels and the severity of covid
19 infection.22

A study by Nete Munk Nielsen et al included 447 individuals who tested positive within the first 3 months of the
SARS-CoV-2 epidemic in Denmark. Overall, it was found that individuals with vitamin D deficiency were at a
higher risk of progressing to a more severe clinical outcome of COVID-19.23

In the study conducted by Basaran N et al, a total of 204 patients with COVID-19 disease were enrolled, out of
which, Vitamin D deficiency was found in 41.7 % (n = 85) of cases and insufficiency was found in 46.0 % (n =
94), while in 12.3 % (n = 25) of cases normal vitamin D levels were found. The odds of having a serious clinical
outcome were increased for vitamin D insufficiency patients 5.604 times (%95 CI:0.633–49.584) and for vitamin
D deficiency patients 38.095 times (%95 CI:2.965–489.50) for each standard deviation decrease in serum
25(OH)D.24

A recent meta-analysis carried out by Dissanayake et al. including nearly 2 million adults and 76 studies concluded
that vitamin D deficiency/insufficiency probably increases susceptibility to COVID-19 and severe COVID-19,
although with a high risk of bias and heterogeneity, whereas association with mortality is less robust. 25

A retrospective single-institution study conducted by Amiel A. Dror et al demonstrated a correlation between

insufficient 25-hydroxyvitamin D (25(OH)D) level prior to COVID-19 infection and increased COVID19 disease
severity and mortality during hospitalization. The study included 1176 patients admitted, out of which 253 had
records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients
with the severe or critical disease (<20 ng/mL [87.4%]) than in individuals with mild or moderate disease (<20
ng/mL [34.3%] p < 0.001). Patients with vitamin D deficiency (<20 ng/mL) were 14 times more likely to have

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severe or critical disease than patients with 25(OH)D ≥40 ng/mL (odds ratio [OR], 14; 95% confidence interval
[CI], 4 to 51; p < 0.001).26

Our study in comparison to the above studies also show a similar association between low vitamin D levels and
increase in the severity of covid 19 infection.

The results of current study can be interpreted with few limitations. First, the study has been conducted in a single
center. Second, there were absence of normal controls. So, keeping these in view a multicenter study with large
number of subjects can be carried out for generation of robust conclusions.

Conclusion
The importance of this hormone in overall health and the prevention of chronic diseases are at the forefront of
research. Numbers of people with vitamin D deficiency are continuously increasing. In our study vitamin D level
is markedly low in hypoxic patients. In conclusion, vitamin D deficiency increases the chance of having severe
disease after infection with covid 19. Hence vitamin D supplementation to COVID 19 patients may be beneficial
in reducing the severity of the disease.

Conflict of interest
The author declared “no conflict of interest”

Funding agency
Self

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